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PYORRHEA  ALVEOLARIS. 


DEDICATED   TO 

Dr.  Matthew  A.  Barber 
A  true  friend,  teacher,  and  scholar. 


Guinea-pig  showing  the  Traumatic  Infective  Variety  of  Pyor- 
rhea artificially  produced.  A,  point  of  trauma  and  infection, 
and  the  point  at  which  the  gum  was  at  the  beginning  of  the 
experiment;  B,  gum  margin  around  the  right  lower  central  in- 
cisor. C,  gum  margin  around  the  left  central  incisor.  The  space 
occupied  between  B  and  C  is  an  active  pocket. 


PYORRHEA 
ALVEOLARIS 


By 
FRIEDRICH  HECKER 

B.Sc,  D.D.S.,  A.M.,  M.D. 

Member  of  the  Academy  of  Science  of  St.  Louis,  Mo.;  Consult.-int 
at  Bell  Memorial  Hospital  of  the  School  of  Medicine,  Uni- 
versity of  Kansas,  Rosedale,  Kansas;  Consultant  at 
St.  Margaret's  Hospital,  Kansas  City,  Kansas 


ILLUSTRATED 


ST.  LOUIS 

V.  MOSBY  COMPANY 

1913 


Plllllllllllllllllilililllllllillllllllllllllllllllllllllllilillllllllllllllllllllllil^ 


Copyright,  1913,  By  C.  V.  Mosby  Company 


1^K  5^ 

14-36- 


Press  of 

C.  V.  Mosby  Company 

St.  Louis 


PEEFACE. 

The  opinions  as  to  the  canse  and  treatment 
of  pyorrhea  are  as  diverse  at  the  present 
time  as  they  were  many  years  ago.  The  most 
common  belief  of  the  dentists  is  that  the  disease 
is  a  local  process.  The  author,  after  careful  ob- 
servation covering  a  number  of  years,  does  not 
agree  with  this  theory,  but  believes  that  the  dis- 
ease is  the  result  of  constitutional  and  exciting 
causes  which  lower  the  vital  resistance  of  the 
alveolar  process,  gum,  and  the  peridental  mem- 
brane. The  body,  in  other  words,  is  out  of  har- 
mony physiologically,  and  as  a  result  thereof, 
manifests  itself  in  the  alveolar  process,  the 
gum,  and  the  peridental  membrane. 

Accepting  the  statement  that  the  above  pos- 
tulates are  correct,  there  are  also  diseases  which 
are  complications  of  pyorrhea.  The  oculist  ex- 
amines the  teeth  and  the  gum  of  his  patients, 
-for  he  has  learned  that  if  they  are  diseased  their 
condition  affects  the  eye  reflexly.  The  aurist 
has  learned  that  unhealthy  teeth  and  gum  are 
factors  of  great  importance  in  diseased  condi- 
tions of  the  eustachian  tube  and  the  middle  ear. 


10  PREFACE 

The  laryngologist  examines  the  teeth  and  the 
gum  for  he,  too,  has  learned  that  they  are 
factors  in  the  production  of  tonsillitis  and  dis- 
eases of  the  throat.  The  internist  of  today  is 
not  like  his  colleagnie  of  a  few  years  ago,  who 
laughed  at  the  possibilities  of  complications  re- 
sulting from  diseased  teeth  and  gum,  for  he  has 
learned  that  they  are  of  importance  in  such  dis- 
eases as  are  the  result  of  micro-organisms,  path- 
ogenic in  type.  The  tonsil,  it  is  taught,  is  one 
of  the  common  avenues  for  the  invasion  of 
micro-organisms  into  the  body.  As  a  rule,  mi- 
cro-organisms are  present  in  pyorrhea  and  are 
held  in  suspension  by  the  pus.  The  pus  is  con- 
stantly exuding  from  around  the  neck  of  the 
tooth  at  the  gum  margin,  being  mixed  with  the 
saliva  and  swallowed.  In  the  act  of  swallowing 
a  portion  of  it  passes  over  the  tonsils.  Some  of 
the  organisms  contained  in  the  mixture  of  saliva 
find  lodgment  in  the  crypts  of  the  tonsils.  After 
an  indefinite  time  they  commence  to  grow  and 
by  their  growth  inflammation  results.  As  a  re- 
sult of  this  process  the  normal  resistance  of  the 
tonsil  is  lowered,  after  which  the  organisms,  in 
all  likelihood,  gain  ingress  into  the  lymph 
stream  and  thence  to  the  general  circulation. 
After  their  ingress  they  are  carried  to  the  finer 


PREFACE  11 

capillaries,  and  if  the  bodily  resistance  is  lo\v» 
tliey  are  lodged  in  them  and  soon  commence  to 
grow.  If  the  point  at  which  this  process  hap- 
pens is  the  endocardium  of  the  heart,  an  en- 
docarditis will  result.  This  is  not  a  mere  dream, 
but  in  all  probability  a  process  which  actually 
occurs. 

From  the  above  examples  can  be  readily  con- 
ceived the  possibilities  resulting  from  diseased 
gum  and  demonstrates  that  pyorrhea  is  a  dis- 
ease which  must  and  will  receive  a  great  deal  of 
attention.  Much  is  to  be  done  and  the  field  of- 
fered the  investigator  is  a  broad  one,  for  very 
little  work  has  been  done  thus  far  on  this  sub- 
ject. In  the  past  it  has  been  looked  upon  as  of 
little  importance;  but  in  all  likelihood  it  is  of 
great  consequence  in  all  departments  of  the 
healing  art.  It  is  a  disease  which  is  amenable 
to  treatment  and  the  author  sincerely  hopes  that 
the  future  will  simplify  and  improve  to  such 
definite  end  that  the  disease  can  be  treated  by 
all  men  of  the  healing  art  and  that  they  will  be 
rewarded  with  success  for  their  efforts. 

Friedrich  Hecker. 

Kansas  City,  Mo., 
November  1,  1913. 


ILLUSTRATIONS 


Guinea-pig  showing  the  Traumatic  Infective  Variety 

of  Pyorrhea Frontispiece 

Fig.  Page 

I.     Position  for  making  a  blood  smear 62 

II.    Arnold  steam  sterilizer 65 

III,  Autoclav   71 

IV.  Burette-bottle  and  wood  holder 73 

V.     Petri  dish 81 

VI.     Hot  air  sterilizer •. 81 

VII.     Medium  laboratory  microtome 97 

VIII.     Longitudinal  section  of  palatine  root 101 

IX.     Cross-section  of  palatine  root 101 

X.     Cross-section  of  palatine  root  and  alveolus  103 
XI.     Cross-section    of    anterior    and    posterior 

buccal  roots  and  the  alveolus 105 

XII.     Cross-section    of    anterior    and    posterior 

buccal  roots,  including  the  alveolus ....  107 

XIII.  Cross-section    of    the    palatine    root    and 

alveolar  process 109 

XIV.  Cross-section  of  anterior  buccal  root  and 

alveolus   Ill 

XV.     Cross-section  of  palatine  root  and  alveolar 

process 113 

XVI.     Cross-section    of   palatine   root,    including 

a  small  island  of  the  alveolar  process. .  115 

XVII.     Cross-section  near  anterior  buccal  root...  117 

XVIII.     Cross-section  from  near  palatine  root. . . .  119 

XIX.     Cross-section    of    anterior    and    posterior 

buccal   roots,   including  the   peridental 

membrane   121 

13- 


14 


ILLUSTRATIONS 


Fig.  Page 

XX.     A  field  magnified  one  thousand  times 123 

XXI.     Platinum  loop  125 

XXII.     Vaccine  container,  with  rubber  cap 127 

XXIII.  Individual  vaccine  container  127 

XXIV.  Showing    position    of    tube    for    collecting 

blood  corpuscles  131 

XXV.     Water  motor  centrifuge  131 

XXVI.     Position  for  making  emulsion  of  bacteria 

and  blood  corpuscles 133 

XXVII.     Position  for  making  mixture  of  bacteria 

and  blood  cells 133 

XXVIII.     Pipette  used  for  mixing  blood  corpuscles 

and  emulsion  of  bacteria 134 

XXIX.     Tiirck's  ruled  hemocytometer 135 

XXX.     A  field  as  observed  when  counting  bacteria 

and  blood  cells 136 

XXXI.     Position  of  arm  for  vaccination  138 

XXXII.     Pipette  and  attached  rubber  hose 142 


CONTENTS 


CHAPTER   I. 
Varieties  of  Pyorrhea.  Page 

Diabetic — Intestinal  Nephritic — Infective — Gastro- 
intestinal Toxemic — Presenile — Senile — Result- 
ing from  Trauma — Resulting  from  Chemical 
Irritants — Resulting  from  Mechanical  Irritants 
— Resulting  from  Thermal  Irritants — Resulting 
from  Bacteriological  Irritants   17-60 

CHAPTER    II. 
Technique  for  Making  a  Blood  Smeak. 
Technique    for    Staining    Slide — Differential    Blood 

Count— Technique  for  Making  Wright's  Stain.        61-66 

CHAPTER  III. 
Technique  for  Making  Stains. 
Technique  for  Staining  Smear  of  Bacteria — For 
Making  Carbol  Gentian — For  Making  Gram's 
lodin  Solution — For  Making  Bismarck-Brown 
Solution — For  Making  Methylene  Blue — For 
Making  Loeffler's  Methylene  Blue  67-69 

CHAPTER    IV. 
Technique  for  Making  Culture  Media. 
Preparation  of  Agar — Preparation  of  Broth — Tech- 
nique for  Tubing  and  Sterilization  of  Culture     , 
Media    70-78 

CHAPTER  V. 
Bacteriology. 
Staphylococcus  Pyogenes  Albus  —  Staphylococcus 
Pyogenes  Aureus  —  Staphylococcus  Pyogenes 
Citreus  —  Staphylococcus  Pyogenes  Fetidis  — 
Streptococcus  Pyogenes — Bacillus  Pyocyaneous 
— Diplococcus  Pneumonia— Leptothrix  Buccalis 
— Spirochseta  Refringens 79-93 

1-5 


16  CONTENTS 

CHAPTER    VI. 
Pathology.  Page 

Preparation  of  Specimen  for  Study — Longitudinal 
Section  of  Palatine  Root — Cross-Section  of  Pal- 
atine Root  and  Alveolus — Cross-Section  of  An- 
terior and  Posterior  Buccal  Roots  and  Alveolus 
— Cross-Section  of  Anterior  and  Posterior  Buc- 
cal Roots  Including  Alveolus — Cross-Section  of 
Palatine  Root  and  Alveolar  Process — Cross- 
Section  of  Anterior  Buccal  Root  and  Alveolus 
— Cross-Section  of  Palatine  Root  and  Alveolar 
Process — Cross-Section  of  Palatine  Root  Includ- 
ing Small  Island  of  Alveolar  Process — Cross- 
Section  Near  Anterior  Buccal  Root — Cross-Sec- 
tion from  Near  Palatine  Root — Cross-Section  of 
Anterior  and  Posterior  Buccal  Roots  Including 
Peridental  Membrane — Field  Magnified  One 
Thousand  Times  94-123 

CHAPTER   VII. 

Technique  foe  Making  Vaccines. 

Containers  for  Vaccines — Sterilization  of  Vaccines.    124-129 

CHAPTER   VIII. 

Technique  fok  Collecting  Blood  Corpuscles. 
Standardization  of  Vaccines  130-136 

CHAPTER   IX. 
Technique  fob  Vaccination. 
Reaction  of  Vaccine 137-140 

CHAPTER   X. 

Technique  fob  Making  Capillary  Pipettes. 

Technique  for  Application  of  Drugs  with  Pipettes. .    141-142 

CHAPTER  XI. 

Local  and  Peophylactic  Treatment. 

Instrumentation    143-146 


PYORRHEA  ALVEOLARIS 


CHAPTER  I. 
Varieties  of  Pyorrhea. 

The  author  has  for  a  number  of  years  kept 
notes  of  observations  made  on  the  gums  and 
teeth  of  patients  afflicted  with  pyorrhea.  In 
each  case  a  history  was  taken,  and  in  addition 
thereto  the  findings  of  an  examination  of  the 
gums  and  the  teeth.  With  these  findings  the 
author  has  classified  tlie  disease  into  the  fol- 
lowing varieties : 

I.  Diabetic  Variety. 

II.  Interstitial  Nephritic  Variety. 

III.  Infective  Variety. 

IV.  Gastro-Intestinal  Toxemic  Variety. 
V,  Pre-senile  Variety. 

VI.     Senile  Variety. 
VII.     Variety  Resulting  from  Trauma. 
VIII.     Variety  Resulting  from  Chemical 
Irritants. 
IX.     Variety  Resulting  from  Mechan- 
ical Irritants. 
X.     Variety  Resulting  from  Thermal 
Irritants. 
XI.     Variety  Resulting  from  Bacteri- 
ological Irritants. 

17 


18  PYORRHEA  ALVEOLARIS 

A  complete  description  of  the  eleven  varie- 
ties mentioned  above  is  given  in  the  following- 
pages  : 

Diabetic  Vaeiety. 

Etiology. — The  diabetic  variety  of  pyorrhea 
is  a  complication  of  diabetes.  It  generally 
manifests  itself  after  the  disease  is  well  estab- 
lished, occurring  between  the  ages  of  25  and 
50.  The  predominant  number  of  sufferers 
which  have  come  under  observation  were  mar- 
ried women,  and  as  a  rule  mothers.  They  have 
not  been  of  the  poorer  class,  but  of  the  middle 
class  and  the  rich — the  greater  number  were 
among  the  rich.  The  sufferer  usually  is  with- 
out worry,  and  leads  a  very  sedentary  life. 

The  exciting  causes — trauma;  chemical,  me- 
chanical, thermal  and  bacteriological  irritants 
— are  of  great  importance.  The  tissues  around 
the  teeth  like  the  other  tissues  of  the  body  are 
poor  in  resistance.  Hence,  any  one  of  the  above 
factors  has  the  ability  to  bring  about  a  local 
destruction  of  the  gum,  the  peridental  mem- 
brane and  the  alveolar  process. 

Pathology. — In  this  variety  the  gum  around 
the  teeth  during  an  acute  exacerbation  is  of  a 
beefy-red  color  in  contrast  to  the  normal  pink 
of  healthy  gum  tissue.     It    is    sensitive,    and 


VAKIETIES  OF  PYORRHEA  19 

on  gentle  pressure  there  appears  at  the  gum 
margin  a  thin  whitish  or  cream  colored  exu- 
date which  is  small  in  amount.  If  the  gum  is 
massaged  a  profuse  hemorrhage  occurs  from 
the  area  thus  treated.  The  hemorrhage  is  very 
persistent  and  difficult  to  control.  In  this  vari- 
ety of  pyorrhea  the  painfulness  of  the  gum  is 
not  relieved  by  bleeding.  It  is  observed  that 
the  teeth  are  markedly  affected  by  extreme  ten- 
derness, which  in  some  instances  is  so  severe 
that  the  patient  constantly  refrains  from  using 
them  in  mastication,  and  is  very  careful  in  con- 
versation or  at  rest  not  to  bring  them  into  oc- 
clusion. The  exacerbations  come  on  at  irreg- 
ular times  and  vary  in  length  of  duration.  One 
can,  with  little  discomfort  to  the  patient  at  the 
time  of  an  exacerbation,  pass  a  thin-bladed  in- 
strument for  a  considerable  distance  between 
the  root  of  the  tooth,  the  gum  and  the  alveolar 
process.  As  the  attack  subsides  the  depth  of  the 
pocket  becomes  less  than  during  the  exacerba- 
tion. The  depth  of  the  pocket,  as  a  rule,  is  de- 
pendent on  the  severity  and  the  number  of  pre- 
vious attacks.  With  each  attack  the  pocket  re- 
appears and  is  increased  in  depth  and  extent 
around  the  root  of  the  tooth.  The  diseased  con- 
dition of  the  gum,  the  peridental  membrane  and 


20  PYORBHEA  ALVEOLAEIS 

the  alveolus  is  progressively  worse  with  each 
exacerbation.  The  teeth,  because  of  the  loss  of 
tissue,  become  greatly  loosened,  in  some  in- 
stances so  loose  that  extraction  is  necessary. 

Bacteriology. — In  the  diabetic  variety  there 
are,  as  a  rule,  a  variety  of  organisms,  with  one 
of  the  staphylococci  predominating. 

Diagnosis.- — The  diagnosis  of  the  disease  is 
made  on  the  history  or  urinary  findings  of  dia- 
betes. This  fact  is  generally  known  to  the  pa- 
tient and  if  not  should  be  confirmed  by  making 
a  test  for  sugar.  (The  Fehling  test  can  be  quan- 
titatively or  qualitatively  made.)  The  beefy- 
red  color  of  the  gum  in  contrast  to  the  normal 
pink  gum  tissue,  the  acute  overwhelming  ex- 
acerbations, the  sweet  odor  of  the  breath,  and 
the  urinary  findings  are  sufficient  to  make  a 
positive  diagnosis  of  this  variety  of  pyorrhea. 

Differential  Diagnosis. — The  diabetic  variety 
is  differentiated  from  the  Interstitial  Nephritic 
Variety  by  the  urinary  findings  which  in  the 
interstitial  nephritic  variety  does  not  contain 
sugar,  but  albumin ;  and  by  the  character  of  the 
gum  around  the  teeth  involved,  which  is  not  of 
a  beefy-red  color.  It  is  differentiated  from  the 
Infective  Variety  by  the  history  and  character 
of  the  onset  of  the  attack;  from  the  Gastro-in- 


VARIETIES  OF  PYORRHEA  21 

testinal  Toxemic  Variety  by  the  sudden  onset, 
soreness  of  the  gum  (which  is  quite  general), 
malaise,  nausea,  and  headache ;  from  the  Excit- 
ing Varieties  by  the  history  and  the  presence 
of  factors  which  have  to  do  with  the  production 
of  this  variety;  namely,  traumatic,  chemical, 
thermal,  mechanical  and  bacteriological  irri- 
tants. After  the  presence  of  any  one  of  these, 
landmarks  are  left  which  cannot  be  confused 
with  the  diabetic  variety  of  pyorrhea. 

Symptomatology. — In  the  diabetic  variety  of 
pyorrhea  the  patient  at  intervals  varying  from 
three  to  six  weeks  has  an  exacerbation  which  is 
ushered  in  by  malaise,  irritability,  nervousness, 
and  pain  which  is  neuralgic  in  character.  The 
length  of  the  exacerbation  is  from  2  to  7  days 
and  in  some  cases  it  becomes  so  overwhelming 
that  the  patient  goes  to  bed.  At  the  commence- 
ment of  the  attack  the  gum  around  the  teeth  in- 
volved is  painful  on  pressure.  The  gum  is 
swollen,  and  bleeds  readily,  and  after  the  hem- 
orrhage has  commenced  it  is  rather  hard  to 
control.  The  teeth  at  the  beginning  of  the  ex- 
acerbation are  not  painful  when  brought  into 
occlusion,  but  as  the  attack  progresses  they  feel 
elongated,  are  loose,  and  painful  when  brought 
together.    The  height  of  the  attack  is  generally 


22  PYORRHEA  ALVEOLABIS 

reached  within  48  hours.  After  this  time  the 
above  described  symptoms  gradually  subside, 
the  gum  and  teeth  involved  feeling  quite  com- 
fortable after  the  eighth  day.  The  attack  hav- 
ing passed  off,  the  color  of  the  gum  again  be- 
comes approximately  normal  and  a  period  of 
rest  is  established.  After  an  indefinite  period 
of  time  another  exacerbation  comes  on  involv- 
ing teeth  which  were  not  attacked  by  the  pre- 
ceding exacerbation,  and  the  teeth  become  so 
loose  that  they  interfere  with  mastication  and 
articulation.  After  the  disease  has  become  well 
established,  the  gum  is  constantly  more  or  less 
hypersensitive  to  slight  pressure  and  bleeds 
freely  when  brushed.  As  a  result  of  these  two 
inconveniences,  the  patient  does  not  care  for  the 
teeth  as  faithfully  as  in  the  beginning  of  the  dis- 
ease, and  consequently  pockets  of  pus  are  many 
times  present  in  the  chronic  stage  of  this  vari 
ety  which,  if  not  cared  for  by  evacuation,  will 
cause  the  patient  great  pain  and  will  burst  on 
the  surface  of  the  gum.  If  this  occurs  it  com- 
plicates the  condition  and  is  a  hindrance  in  the 
treatment. 

Prognosis. — The  prognosis  of  the  diabetic 
variety  of  pyorrhea  is  dependent  on  the  age  of 
the  patient  and  duration  of  the  disease.    As  a 


VARIETIES  OP  PYORRHEA  23 

rule  a  prognosis  of  fairly  good  results  can  be 
offered  the  patient. 

Treatment. — The  hygienic  treatment  in  the 
diabetic  variety  is  of  great  importance,  and 
thorough  prophylaxis  on  the  part  of  the  patient 
and  the  dentist  is  necessary.  If  the  disease  is 
characterized  by  the  presence  of  pus  at  all 
times  with  an  increased  amount  during  an  ex- 
acerbation, the  first  step  in  the  treatment  is  for 
the  physician  to  prescribe  a  diabetic  diet  and 
treatment,  which  will  raise  the  immunity  of  the 
patient  generally  and  especially  the  immunity 
of  the  tissues  on  which  the  teeth  depend  for 
their  position  and  relation.  The  physician  hav- 
ing prescribed,  the  next  step  is  vaccination  of 
the  patient  with  an  autogenous  bacteeial.  vac- 
cine. 

Interstitial  Nephritic  Variety. 

Etiology. — The  interstitial  nephritic  variety 
of  pyorrhea  is  in  all  likelihood  a  complication  of 
interstitial  nephritis  and  occurs  after  the  forti- 
eth year.  This  variety  of  the  disease  is  found 
most  often  in  men,  although  it  is  sometimes  ob- 
served in  women.  The  social  conditions  are  of 
no  importance  in  this  variety,  for  the  disease 
is  found  among  paupers  as  well  as  among  the 


24  PYORRHEA  ALVEOLARIS 

rich.  The  occupation  of  the  afflicted  person 
may  be  that  of  a  laborer  or  banker. 

In  the  modern  teachings  of  medicine  it  is  held 
that  alcohol  is  an  etiological  factor  in  the  pro- 
duction of  nephritis.  Hence,  as  a  result  of  this 
deduction,  alcoholism  must  first  be  considered 
as  a  factor  of  great  importance  in  the  produc- 
tion of  this  variety  of  pyorrhea.  The  next  most 
important  factor  is  the  bacteria,  for  in  this  va- 
riety the  immunity  of  the  tissues  around  the 
teeth  is  very  low  and  as  a  result  thereof  the}^ 
find  them  an  excellent  field  for  their  growth. 
The  presence  of  the  products  of  bacteria  dimin- 
ish the  local  and  general  immunity,  and  if  the 
sufferer  is  an  alcoholic  the  immunity  is  further 
diminished. 

The  remaining  exciting  causes  are  the  me- 
chanical irritants;  namely,  ill-fitting  plates, 
bridges,  band  or  porcelain  crowns,  tartar  that 
is  of  a  soft  putty  consistency  and  of  a  pale  yel- 
low color  at  the  gingival  margin.  Trauma,  if 
of  the  contused  variety,  increases  the  dimin- 
ished vital  resistance  of  the  tissues,  and  they 
are  lost,  either  by  the  action  of  the  bacteria  and 
their  products  or  by  local  necrosis.  The  thermal 
irritants  such  as  very  hot  food  or  drinks,  are 
capable  of  producing  an  irritation  of  such  se- 


VARIETIES  OF  PYORRHEA  25 

verity,  which,  if  not  treated,  many  times  termi- 
nates in  the  destruction  of  a  small  or  large 
amount  of  the  gum  tissue. 

Pathology. — The  onset  of  the  interstitial  ne- 
phritic variety  and  after  its  establishment  is 
characterized  by  mild  exacerbations.  This  va- 
riety of  pyorrhea  is  very  slow  in  its  progress, 
the  tooth  or  teeth  first  involved  being  only 
slightly  painful  on  occlusion,  with  no  looseness. 
As  the  disease  progresses,  the  teeth  gradually 
become  loosened  and  the  teeth  on  occlusion  be- 
come painful.  The  looseness  of  the  teeth  is  in- 
creased when  an  exacerbation  comes  on  and  re- 
mains so  during  it.  The  gum  gradually  recedes 
from  the  necks  of  the  teeth,  exposing  the  roots 
for  a  variable  distance,  depending  on  the  dura- 
tion of  the  existence  of  the  malady.  The  roots 
of  the  teeth  in  some  cases  are  smooth  while  in 
others  they  are  rough,  having  a  fine  deposit  on 
the  surface  that  feels  flinty  when  rubbed  with 
an  instrument.  The  gum  during  an  exacerba- 
tion has  a  dark  bluish-red  color.  It  is  swollen 
and  painful  on  pressure,  but  if  the  pressure  is 
continued  the  pain  becomes  very  slight  and 
there  exudes  from  the  gum  margin  a  thin,  white 
exudate  which  in  some  instances  has  a  very  foul 
odor.    This  odor  is  observed  many  times  by  the 


26  PYORRHEA  ALVEOLARIS 

patient  who  as  a  result  calls  on  the  dentist,  com- 
plaining of  this  odor  and  the  looseness  of  the 
teeth. 

Bacteriology. — In  this  variety  of  pyorrhea 
it  is  found  microscopically  that  a  variety  of 
organisms  are  present,  the  staphylococcus 
pyogenes  fetidis  being  the  predominaitng  one 
in  the  smear  and  culture. 

Diagnosis. — The  diagnosis  is  made  on  the 
character  of  the  onset  of  the  disease,  the  age, 
the  sex,  the  color  of  the  gum  as  compared  to  the 
normal  pink  of  healthy  gum  tissue,  the  history 
of  interstitial  nephritis,  and  the  slow  progres- 
sive invasion  of  the  disease  to  the  approximal 
and  distant  teeth  from  the  teeth  first  involved 
by  the  disease. 

Differential  Diagnosis. — This  variety  is  dif- 
ferentiated from  the  Diabetic  Variety  by  the 
character  of  the  onset,  the  age,  and  the  color 
of  the  gum.  In  this  variety  tartar  is  generally 
present,  while  in  the  diabetic  variety  it  may  or 
may  not  be  present.  The  tartar  is  as  a  rule 
very  hard,  and  is  firmly  attached  to  the  root  of 
the  tooth,  while  in  the  diabetic  variety  the  tartar 
is  soft  and  does  not  adhere  firmly  to  the  root 
of  the  tooth.  It  is  differentiated  from  the  In- 
fective Variety  by  the  history,  the  character  of 


VARIETIES  OF  PYORRHEA  27 

the  onset,  the  invasion,  and  the  color  of  the 
gum;  from  the  Gastro -intestinal  Toxemic  Vari- 
ety by  the  character  of  the  onset  and  the  phys- 
ical condition  of  the  patient;  from  the  Prese- 
nile Variety  by  the  history,  the  color  and  text- 
ure of  the  gum,  and  the  recession  of  the  gum  at 
the  necks  of  the  teeth  involved;  from  the  Se- 
nile Variety  by  the  gradual  recession  of  the 
gum  around  all  of  the  remaining  teeth ;  from  the 
Exciting  Varieties  by  the  evidence  which  they 
leave  on  the  tissue! 

Symptomatology. — The  onset  of  the  intersti- 
tial variety  is  insidious,  the  patient  stating  that 
a  positive  date  of  the  first  manifestation  of  the 
disease  cannot  be  recalled.  It  is  found  that  the 
gum  and  teeth  involved  have  for  some  time  been 
slightly  painful,  but  at  the  time  of  calling  on  the 
dentist  this  painfulness  is  much  increased.  This 
is  probably  due  to  an  exacerbation  and  if  the 
patient  is  questioned  it  is  learned  that  in  the 
beginning  of  the  disease  these  attacks  were 
very  mild,  but  that  they  have  gradually  in- 
creased as  the  condition  became  worse. 

The  invasion  like  the  onset  is  a  very  gradual 
process.  It  may  or  may  not  attack  the  gum 
and  tooth  which  is  adjacent  to  the  tooth  affected 
by  this  disease.    It  may  attack  a  tooth  on  the 


28  PYORRHEA  ALVEOLARIS 

opposite  side  of  the  mouth,  either  in  the  lower 
or  the  upper  jaw.  The  invasion  of  the  disease 
in  all  probability  is  by  way  of  the  blood  stream 
or  by  way  of  the  cancelated  portion  of  the  al- 
veolar process  after  the  establishment  of  the 
disease.  The  course  of  the  disease  is  very  slow, 
involving  one  tooth  and  then  another  until  all 
of  the  teeth  are  more  or  less  affected. 

Prognosis.— The  prognosis  is  dependent  on 
the  duration  of  the  existence  of  the  disease  and 
the  severity  of  the  nephritis.  If  the  physical 
condition  of  the  patient  is  fairly  good  a  better 
prognosis  can  be  offered  than  if  it  is  poor. 

Treatment. — The  treatment  of  the  gum  and 
mouth  should  be  rigid  and  thorough  prophy- 
laxis. The  systemic  condition  of  the  patient 
should  be  looked  after  by  the  family  physician. 
The  physician  should  also  prescribe  such  treat- 
ment which,  when  given  with  the  autogenous 
BACTERIAL  VACCINES,  will  assist  them  in  raising 
the  immunity  of  the  patient. 

Infective  Variety. 

Etiology. — The  infective  variety  may  occur 
at  any  age  after  puberty.  It  is  not  selective  as 
to  sexes,  social  conditions  or  occupation.  Pre- 
vious diseases  have  much  to  do  with  the  pro- 


VARIETIES  OF  PYORRHEA  29 

diiction  of  this  variety,  especially  if  they  are  of 
that  type  which  is  debilitating,  for  by  this  action 
they  lower  the  immunity  of  the  sufferer  and 
thus  subject  the  gum,  peridental  membrane 
and  alveolus  of  the  patient  to  the  action  of 
micro-organisms  and  their  products. 

The  exciting  causes,  like  the  predisposing,  in 
all  probability  are  factors  of  great  importance. 
Trauma  of  the  gum  is  produced  by  the  use  of  a 
tooth-pick,  a  pin,  the  blade  of  a  knife,  or  blunt 
instrument,  or  by  a  blow  upon  the  tooth  of  suf- 
ficient severity  to  loosen  it,  or  upon  the  gum 
tissue  producing  contusion.  The  chemical  ir- 
ritants by  their  action  upon  the  gum  tissue  pro- 
duce an  irritation  followed  by  swelling  which 
forms  a  pocket  at  the  gingival  margin,  offer- 
ing an  excellent  place  for  the  growth  of  bacte- 
ria. Mechanical  irritants;  namely,  ill-fitting 
crowns  and  bridges,  act  as  irritants  to  the  gum 
tissue.  The  thermal  irritants,  especially  hot  tea 
or  coffee  and  hot  food,  are  capable  of  produc- 
ing sufficient  trauma  and  in  many  instances  a  de- 
struction of  the  gum  tissue  around  a  tooth  or 
teeth  ensues.  If  this  occurs  inflammation  of 
the  gum  results  and  a  focus  of  infection  is  es- 
tablished. The  local  immunity  is  impaired  and 
the  process  of  destruction  continues  until  the 


30  PYORRHEA  ALVEOLARIS 

tissues  re-establish  an  immunity  capable  of  pro- 
tecting the  remaining  tissue.  The  bacteriolog- 
ical irritants  are  of  great  importance,  for  by 
their  presence  they  bring  about  such  reactions 
on  the  tissues  in  which  they  are  present  that 
the  function  of  the  tissues  are  impaired.  As 
a  result  of  this  impairment  the  resistance  of 
the  tissue  is  lowered,  after  which  not  only  does 
this  reaction  continue,  but  the  bacteria  grow 
more  abundantly  and  the  adjacent  tissues  are 
attacked,  the  disease  soon  involving  the  gum 
and  the  adjacent  teeth  of  the  upper  and  the 
lower  jaw.  The  chronic  variety  is  a  progres- 
sive stage  of  the  acute  variety. 

Pathology. — The  acute  infective  variety  is 
characterized  by  localized  inflammation  of  the 
gum  at  the  neck  of  the  tooth;  or  this  inflamma- 
tory process  may  involve  the  gum  tissue  of  all 
the  teeth  and  the  mucous  membrane  of  the 
mouth.  The  swollen  gum  varies  in  color  from 
a  light  to  a  dark  bluish-red  and  is  firm  on  pal- 
pation. The  swelling  causes  the  gum  to  loosen 
at  the  gingival  margin  and  a  pocket  is  estab- 
lished, which,  if  massaged,  brings  to  the  gingi- 
val margin  a  small  bead  of  exudate  that  is  whit- 
ish in  color  and  adheres  firmly  to  the  gum.  On 
microscopic  examination  it  is  found  to  be  com- 


VAEIETIES  OP  PYORRHEA  31 

posed  of  pus  cells,  epithelial  cells,  bacteria,  of 
one  predominant  variety,  phagocytes  and  gran- 
ular material.  The  roots  of  the  teeth  involved 
by  the  infection  are  denuded  of  the  gum  and  the 
peridental  membrane,  which  is  variable  in 
amount.  A  continuation  of  the  disease  is  char- 
acterized by  destruction  of  the  alveolus  and  a 
recession  of  the  gum  below  the  focus  of  the  in- 
fection. An  examination  of  the  root  reveals  no 
deposit,  and  its  surface  is  quite  smooth. 

In  the  chronic  variety  the  gum  is  not  as  badl}^ 
swollen  as  in  the  acute  and  on  palpation  feels 
quite  spongy.  The  tinge  of  the  gnim  is  a  deeper 
blue  than  that  observed  in  the  acute  variety. 
The  pus  pocket  is  greater  in  extent  and  on  gen- 
tle massage  there  exudes  at  the  gum  margin  a 
variable  amount  of  exudate  which  varies  in 
color  from  a  white  to  a  creamy  yellow.  The  ex- 
posed roots  of  the  teeth  show  in  this  variety  a 
deposit  variable  in  amount  and  density.  The 
color  of  this  deposit  is  a  dark  reddish-brown. 
It  adheres  to  the  root  of  the  tooth  very  tena- 
ciously. 

Bacteriology. — In  the  infective  variety  the 
color  of  the  gum  around  the  teeth  involved  va- 
ries from  a  light  to  a  dark  bluish-red  in  con- 
trast to  the  normal  pink.    At  first  there  is  a  feel- 


32  PYORRHEA  ALVEOLARIS 

ing  of  irritation  of  the  gum,  which  gradually 
progresses  until  the  gums  around  the  diseased 
teeth  become  painful  and  the  teeth  involved  be- 
come somewhat  loose  and  slightly  elongated. 
At  variable  times  there  are  exacerbations,  the 
onset  of  which  may  or  may  not  be  ushered  in  by 
a  feeling  of  malaise  and  headache.  These  symp- 
toms are  soon  afterward  followed  by  an  inflam- 
mation of  the  gum  and  the  peridental  mem- 
brane, producing  a  very  uncomfortable  feeling 
of  the  teeth  if  the  disease  is  well  advanced.  The 
duration  of  the  attack  varies  from  two  to  five 
days,  after  which  the  gum  and  teeth  rapidly 
return  to  an  approximately  normal  state,  and 
again  feel  quite  comfortable. 

The  chronic  infective  variety  follows  the 
acute  and  is  an  advanced  stage  of  it.  It  is  char- 
acterized by  a  constant  inflammation  of  the 
gum  around  the  affected  teeth.  The  swelling  is 
slight  and  the  feeling  of  irritation  of  the  gum  is 
constantly  present.  The  teeth  are  variably 
loosened.  The  gum  around  the  teeth  feels 
spongy  to  the  touch.  The  color  is  a  dark  red- 
dish-blue in  contrast  to  the  normal  pink.  It  is 
separated  from  that  portion  of  the  root  of  the 
tooth  over  which  it  lies. 

Differential  Diagnosis. — The  acute  infective 


VAEIETIES  OP  PYORRHEA  33 

variety  is  differentiated  from  the  Diabetic  Vari- 
ety by  the  color  of  the  gum,  which  in  the  dia- 
betic is  a  beefy-red  while  in  this  variety  it  va- 
ries in  color  from  a  light  to  a  dark  bluish-red. 
It  is  differentiated  from  the  Interstitial  Ne- 
phritic Variety  by  the  age  which  is  generally 
after  the  fortieth  year,  while  in  this  variety  it 
generally  occurs  at  any  time  after  eruption  of 
the  permanent  teeth.  In  the  interstitial  ne- 
phritic variety  the  recession  of  the  gum  is  a 
gradual  process,  while  in  the  acute  infective 
variety  it  is  a  rapid  process.  At  no  time  is  the 
amount  of  swelling  as  great  in  the  interstitial 
nephritic  as  is  observed  in  this  variety.  The 
gum  is  slightly  painful  on  pressure  in  the  in- 
terstitial nephritic,  while  in  the  acute  infective 
variety  it  is  exceedingl}^  painful  on  the  slightest 
pressure.  This  variety  is  differentiated  from 
the  Presenile  Variety  by  the  age,  which  is  be- 
tween 25  to  40  years.  The  pre-senile  variety  is 
a  slow  progressive  process  destroying  the  gum, 
peridental  membrane  and  the  alveolar  process, 
which,  if  accompanied  by  suppuration,  greatly 
increases  the  destruction  of  the  tissues  on 
which  the  position  tooth  is  dependent.  The  gum 
tissue  in  the  pre-senile  variety  is  firm  and  hard, 
has  a  normal  pink  color,  and  is  not  painful  on 


34  PYORRHEA  ALVEOLARIS 

pressure.  In  the  infective  variety,  whether 
acute  or  chronic,  the  gum  is  swollen  and  pain- 
ful on  pressure.  In  the  pre- senile  variety  the 
exposed  portion  of  the  root  presents  a  deposit 
which  varies  in  color  from  a  light  yellow  to  a 
reddish-brown  and  in  hardness  from  a  soft 
chalky  to  a  flinty  consistency.  In  the  Senile 
Variety  there  is  a  general  shrinkage  of  the 
gum  around  all  of  the  remaining  teeth.  The 
gum  is  firm  to  the  touch,  normal  in  color,  and 
on  massage,  a  small  amount  of  exudate  may  or 
may  not  appear  at  the  gingival  margin.  If  the 
deposit  is  present  it  is  yellow  in  color,  and  of  a 
chalky  consistency.  There  is  a  general  loosen- 
ing of  all  of  the  remaining  teeth.  The  Gastro- 
intestinal Toxemic  Variety  is  differentiated 
from  the  acute  and  chronic  infective  varieties 
by  exacerbations  which  are  characterized  by 
headache,  nausea,  and  intestinal  disturbances. 
These  are  followed  by  a  marked  feeling  of  irri- 
tation of  the  gum  and  the  peridental  membrane, 
the  teeth  become  very  sensitive  on  occlusion 
and  are  slightly  loosened.  The  Exciting  Varie- 
ties are  differentiated  from  the  infective  vari- 
eties by  such  evidence  which  presents  itself  as 
a  result  of  trauma,  chemical,  mechanical,  ther- 
mal, and  bacteriological  irritants. 


VARIETIES  OP  PYORRHEA  35 

Symptomatology. — The  acute  variety  of  this 
disease  is  characterized  by  a  sudden  feeling  of 
irritation  of  the  gum  at  the  necks  of  the  teeth 
affected.  This  feeling  is  soon  after  followed  by 
tenderness  and  swelling.  The  gum  around  the 
teeth  involved  varies  in  color  from  a  light  to  a 
dark  bluish-red  and  is  firm  to  the  touch.  At 
the  neck  of  the  tooth  the  gum  retracts  from  it 
and  forms  a  pocket.  The  teeth  as  a  rule  in- 
volved by  the  disease  are  loose,  feel  elongated 
to  the  patient,  and  are  painful  when  brought  in- 
to occlusion. 

The  chronic  variety  is  a  continuation  of  the 
acute  stage  and  is  characterized  by  an  invasion 
of  the  disease  to  many  of  the  teeth  of  the  up- 
per and  the  lower  jaw.  The  gum  in  this  stage 
is  of  a  deeper  blue  color  than  observed  in  the 
acute  stage,  but  is  not  as  badly  inflamed  and 
feels  spongy  to  the  touch.  The  pockets  are 
larger  and  the  exposed  portion  of  the  roots 
show  a  deposit.  The  teeth  are  loose  and  are 
quite  painful  when  brought  into  occlusion. 

Prognosis. — The  prognosis  of  the  infective 
variety  is  as  a  rule  very  good. 

Treatment. — The  hygiene  of  the  mouth  is 
first  in  importance  in  the  treatment  of  this  va- 
riety and  should  consist  of  a  good  antiseptic 


36  PYORRHEA  A1.VE0LARIS 

moutli  wash  wMcli  is  astringent.  The  charac- 
ter of  the  diet  should  be  determined  and  if 
found  faulty  should  be  corrected  by  the  physi- 
cian. If  the  patient  is  poorly  nourished  such 
systemic  treatment  should  be  instituted  as 
will  improve  the  general  health.  The  immunit}^ 
of  the  patient  should  be  raised  by  drugs  and 
autogenous  bacteeial  vaccines. 

Gastro-intestinal  Toxemic  Variety. 

Etiology. — This  variety  of  pyorrhea  may  ap- 
pear at  any  time  after  the  eruption  of  the  per- 
manent teeth.  The  sexes  are  equally  affected. 
It  is  found  in  the  middle  and  wealthy  classes, 
more  often  in  the  latter.  It  is  most  often  found 
among  extravagant  livers  who  lead  sedentary 
lives.  It  may,  however,  occur  in  the  mouth  of 
any  one  suffering  with  a  gastro-intestinal  tox- 
ema.  Previous  diseases  which  have  the  abil- 
ity to  leave  behind  a  diminished  functionating 
gastro-intestinal  apparatus  and  diminished 
function  of  the  organs  of  elimination  are  of  im- 
portance in  this  variety. 

Pathology. — The  gum  and  the  mucous  mem- 
brane of  the  mouth  are  swollen  and  painful  dur- 
ing an  exacerbation.  The  gum  at  the  necks  of 
the  teeth  varies  in  color  from  a  very  bright  to  a 


VARIETIES  OF  PYORRHEA  37 

very  dark  red  as  compared  to  the  normal  pink 
color.  It  is  very  firm  on  pressure  and  greatly 
increased  in  size  as  compared  to  tlie  normal 
gum  at  this  point.  The  swelling  of  the  gum 
causes  it  to  retract  at  this  point  and  by  so  doing 
pockets  are  established.  The  exudates  found 
in  the  pockets  are  rich  in  substances  in  which 
bacteria  grow  readily.  The  depth  of  the  pock- 
ets depends  on  the  previous  number  of  attacks 
and  on  the  extent  of  the  infection  which  accom- 
panied them.  If  the  disease  is  of  some  stand- 
ing, gentle  massage  of  the  pockets  will  bring  to 
the  margin  an  exudate  which  varies  in  color 
from  a  pale  white  to  a  yellow,  and  from  a  thin 
watery  to  a  creamy  consistency.  When  exam- 
ined under  the  microscope  it  shows  pus  cells, 
fibrinous  material,  granular  debris,  and  a  vari- 
ety of  bacteria.  The  teeth  affected  by  the  exacer- 
bation become  very  loose  and  are  painful  on 
occlusion.  Sordes  are  observed  on  the  teeth, 
the  tongue  is  coated,  and  the  breath  as  a  rule  is 
foul  smelling. 

Bacteriology. — The  bacteria  found  in  this  va- 
riety are  the  staphylococcus  pyogenes  albiis, 
aureus,  and  fetidis  (especially  the  fetidis)  dip- 
lococci,  spirochcvta  refringens,  and  sapliro- 
phytes. 


38  PYORRHEA  ALVEOLARIS 

Diagnosis. — The  diagnosis  of  this  variety  is 
made  on  the  history  of  the  onset  of  the  exacer- 
bation, the  wide- spread  inflammation  of  the 
gum  and  the  mucous  membrane,  the  swelling 
and  the  color  of  the  gum,  and  symptomatology. 

Differential  Diagnosis. — This  variety  is  dif- 
ferentiated from  the. Diabetic  Variety  by  the 
color  of  the  gum  which  in  the  diabetic  variety 
is  a  beefy  red.  In  the  diabetic  variety  there  is 
a  history  of  diabetes  and  the  teeth  affected  are 
fewer  in  number.  It  is  differentiated  from  the 
Interstitial  Nephritic  Variety  by  the  history  of 
the  interstitial  nephritis,  the  presence  of  albu- 
min in  the  urine,  the  color  of  the  gum,  and  the 
gum  is  not  as  greatly  swollen;  from  the  Pre- 
senile Variety  by  the  gradual  recession  of  the 
gum.  The  gum  is  not  painful  to  pressure  in  the 
pre-senile  variety.  From  the  Acute  and  Chronic 
Infective  Varieties  it  is  differentiated  by  the 
history  of  the  onset  of  the'  disease.  The  gum  in 
the  infective  variety  is  affected  quite  exten- 
sively and  the  consistency  of  the  gum  in  the 
chronic  variety  is  different  from  that  found  in 
this  variety.  It  is  differentiated  from  the  Se- 
nile Variety  by  the  history,  the  great  amount 
of  recession  of  the  gum,  the  constant  looseness 
of  the  teeth,  the  absence  of  teeth,  and  the  age 
of  the  patient. 


VAKIETIES  OP  PYORRHEA  39 

Symptomatology. — The  onset  of  this  variety 
is  usually  sudden  and  is  characterized  by  a  feel- 
ing of  soreness  and  pufifiness  of  the  gum.  After 
the  onset  the  condition  continues  to  become 
worse  and  after  24  hours  the  gum  around  the 
teeth  becomes  very  painful  on  pressure  and  the 
teeth  variably  loosened  and  feel  elongated  to 
the  patient.  The  gum  bleeds  readily  when 
brushed  but  after  the  bleeding  feels  greatly  re- 
lieved. In  some  instances  the  gum  at  the  necks 
of  the  teeth  becomes  so  loose  that  in  the  act  of 
mastication  of  the  soft  foods  which  the  patient 
eats,  particles  of  the  food  crowd  into  the  pock- 
ets and  greatly  irritate  it,  causing  pain.  The 
patient  complains  of  a  headache  and  nausea 
which  is  variable  in  intensity,  does  not  care  for 
food  and  feels  best  when  lying  down.  The 
above  symptoms  are  mild  in  character  in  the 
beginning  of  the  disease,  but  as  the  disease 
progresses  become  worse  at  each  exacerbation, 
and  at  the  time  of  the  visit  to  the  dentist  are 
severe  in  character.  In  some  cases  swelling  is 
located  at  a  considerable  distance  downward 
from  the  gum  margin.  Slight  pressure  over 
this  point  causes  the  patient  to  wince  and  ob- 
ject to  repetition  of  the  procedure.  Pus  appears 
if  this  point  is  lanced.     The  pain  is,  as  a  rule, 


40  PYORRHEA  ALVEOLARIS 

instantly  relieved  after  it  is  opened.  The  dura- 
tion of  the  exacerbations  varies  from  three  to 
five  days,  after  which  the  tenderness  of  the  gum 
and  sensitiveness  of  the  teeth  gradually  sub- 
side. The  inflammation  disappears  and  the 
gum,  teeth  and  mucous  membrane  gradually  re- 
turn to  a  stage  of  quiet,  during  which  they  feel 
quite  comfortable  to  the  patient. 

Prognosis. — The  prognosis  of  this  variety  is 
good. 

Treatment. — The  treatment  should  be  rigid 
prophylaxis.  An  antiseptic  mouth-wash  is  nec- 
essary. The  diet  is  of  paramount  importance 
as  it  is  in  all  probability  the  cause  of  the  dis- 
ease. A  patient  suffering  from  this  variety  is 
usually  very  indiscriminate  and  as  a  result  is 
suffering  from  gastro-intestinal  toxema,  which 
greatly  impairs  the  organs  of  elimination. 
After  a  diagnosis  has  been  made  the  patient  is 
sent  to  the  family  phj^sician  with  a  note  stating 
the  findings  and  advising  that  he  be  treated  for 
a  gastro-intestinal  toxema.  The  autogenous 
BACTERIAL  vACCHsTES  are  of  great  value  when  as- 
sisted by  the  administration  of  drugs  and  in- 
strumentation of  the  affected  teeth. 


VAEIETIES  OP  PYORRHEA  41 

Pre- Senile  Variety. 

Etiology. — This  variety  of  pyorrliea  mani- 
fests itself  between  the  ages  of  25  and  40  years 
of  age.  It  is  observed  in  women  more  often 
than  in  men.  Its  occurrence  is  no  donbt  equal 
in  the  sexes,  but  the  reason  more  Avomen  are 
seen  suffering  from  this  variety  is  because 
they  are  more  particular  about  their  teeth. 

The  social  conditions  have  a  considerable 
influence  in  the  production  of  this  disease.  Rich 
foods  and  alcohol,  when  taken  in  excess,  have 
a  marked  influence  in  its  production,  hence  this 
variety  is  not  one  ordinarily  observed  among 
the  lower  classes,  but  among  the  middle  class 
and  the  rich. 

The  exciting  causes;  namely,  trauma,  chem- 
ical, mechanical,  thermal,  and  bacteriological 
irritants,  when  superimposed  upon  the  condi- 
tion in  its  beginning  have  no  doubt  much  to 
do  with  the  destruction  of  the  gum  tissue 
around  the  teeth. 

Patholofiy. — The  pre-senile  variety  shows  a 
variable  recession  of  the  gum  at  the  necks  of 
the  teeth.  The  gum  on  examination  feels  firm 
to  the  touch  and  on  vigorous  massage  is  slightly 
painful.    The  gum  does  not  bleed  readily  and 


42  PYOERHEA  ALVEOLARIS 

an  exudate  is,  as  a  rule,  absent.  If  present  it 
is  very  small  in  amount,  its  consistency  is 
watery  and  the  color  white.  The  shrinkage  of 
the  gum  is  probably  preceded  by  a  destructive 
process  of  the  alveolus  and  the  peridental  mem- 
brane. This  process  may  be  local  or  it  may  be 
general  around  the  root  of  a  tooth  or  the  roots 
of  molars.  This  variety  is  in  all  likelihood  one 
of  impaired  nutrition  of  the  gums,  peridental 
membrane  and  the  alveolar  process.  The  im- 
paired function  is  accompanied  or  followed  by 
a  lowered  immunity,  if  the  degenerating  proc- 
ess does  not  right  itself  within  certain  limits 
by  the  regeneration  of  the  lost  tissues  or  by 
their  replacement  with  connective  tissue.  The 
degenerated  tissues  are  partially  or  totally  de- 
stroyed by  nature,  by  absorption,  or  by  the 
action  of  such  irritants  as  have  the  ability  to 
destroy  tissues  with  which  they  come  in  con- 
tact; namely,  bacteria,  their  products,  and  sucli 
chemical  irritants  as  are  present  locally  or  con- 
tained in  the  saliva.  The  roots  of  the  teeth  af- 
fected may  or  may  not  show  a  deposit,  which, 
if  present,  varies  in  color  from  a  light  yellow  to 
a  reddish-brown,  and  in  hardness  from  a  chalky 
to  a  flinty  consistency.  Many  times  when  the 
deposit  is  present,  it  acts  as    an   irritant   fol- 


VARIETIES  OF  PYORRHEA  43 

lowed  by  inflammation  of  the  tooth  and  forms 
a  pocket  in  which  bacteria  grow  readily.  If  the 
inflammation  does  not  subside  the  bacteria  and 
their  products  contained  in  the  pocket  bring 
about,  sooner  or  later,  a  destruction  of  the 
gum  in  which  the  pocket  is  located,  and  some- 
times destruction  of  the  peridental  membrane 
and  the  alveolus.  Many  times  the  alveolus  and 
the  peridental  membrane  of  one  tooth  are  at- 
tacked by  the  disease ;  in  which  event  it  is  self - 
limited,  and  after  their  destruction  the  gum 
gradually  shrinks  until  it  is  below  the  point  of 
their  destruction.  After  which  no  further 
destruction  of  the  gum,  peridental  membrane 
and  alveolus  occurs. 

Diagnosis. — The  diagnosis  of  the  pre-se- 
nile  variety  is  made  on  the  age  which  varies 
from  25  to  40  years.  There  is  as  a  rule  a  reces- 
sion of  the  gum  from  around  the  necks  of  the 
teeth.  If  the  gum  is  massaged  it  does  not  bleed 
readily  and  has  a  normal  feeling  on  palpation. 
The  color  of  the  gum  is  a  normal  pink.  If,  how- 
ever, the  condition  is  complicated  by  a  pocket, 
the  gum  is  inflamed  and  a  variable  amount  of 
pus  appears  on  massage. 

Differential  Diagnosis. — This  variety  is  dif- 
ferentiated from  the  Diabetic  by  the  color  of 


44:  PYORRHEA  ALVEOLARIS 

the  gum.  In  the  diabetic  the  gum  on  massage 
bleeds  readily,  while  in  this  variety  it  does  not. 
In  this  variety  the  gum  gradually  recedes  from 
around  the  necks  of  the  teeth,  while  in  the  dia- 
betic it  does  not.  Tartar  may  or  may  not  be 
present,  while  in  the  diabetic  it  may  or  may  not 
be  present.  This  variety  is  differentiated  from 
the  Interstitial  Nephritic  Variety  by  the  age  of 
the  patient,  the  history  of  a  nephritis,  the  pres- 
ence of  variable  sized  pockets  around  the  roots 
of  the  teeth  affected,  and  by  the  color  of  the 
gum;  from  the  Gastro-intestinal  Toxemic  Va- 
riety by  the  history  and  the  character  of  the 
onset;  from  the  Senile  Variety  by  the  age,  the 
history,-  and  the  evidence  of  lost  teeth  and  loose 
teeth  with  a  general  shrinking  of  the  gum  tis- 
sue around  the  remaining  teeth. 

Symptomatology. — The  onset  of  this  variety 
is  insidious.  The  patient  does  not  really  know 
when  the  disease  first  commenced,  but  states 
that  for  a  number  of  years  at  varying  intervals 
there  have  been  periods  during  which  the  gum 
around  the  tooth  or  teeth  affected  has  been 
slightly  swollen  and  tender.  The  disease  may 
be  confined  to  one  molar  or  incisor,  the  teeth  on 
either  side  of  which  are  not  involved.  The  mild- 
ness at  the  onset  and  during  the  progress  of 


VARIETIES  OF  PYORRHEA  45 

the  disease,  readily  explains  why  the  patient 
did  not  observe  the  condition  until  the  teeth  ad- 
jacent to  the  tooth  first  affected  by  the  disease 
commenced  to  undergo  the  same  process — that 
of  a  slov^  progressive  destruction  of  the  gum, 
peridental  membrane,  and  the  alveolar  process. 
After  an  indefinite  time  this  is  followed  by 
looseness  of  the  tooth  or  teeth  which  greatly  in- 
conveniences the  patient  in  mastication  and  ar- 
ticulation, with  a  deformity  of  the  position  of 
the  teeth  and  the  gum  around  the  necks  of  the 
affected  teeth. 

Prognosis, — The  prognosis  is  bad.  If  this 
variety  of  pyorrhea  is  complicated  by  an  infec- 
tion the  prognosis  is  good  as  far  as  the  infec- 
tion is  concerned,  but  not  as  to  a  cure  of  the 
disease. 

Treatment. — The  treatment  should  be  rigid 
prophylaxis,  and  the  patient  given  a  mouth 
wash,  which  is  astringent  and  stimulating  to  the 
gums.  The  diet  should  be  corrected  by  the  fam- 
ily physician  if  found  faulty.  The  general 
treatment  should  be  systemic  and  local.  If  the 
disease  is  accompanied  by  pus  an  autogenous 
BACTEKiAL  VACCINE  slioukl  be  administered.  Mas- 
sage of  the  gum  and  instrumentation  should  be 
instituted  as  indicated. 


46  pyorrhea  alveolaris 

Senile  Vakiety. 

Etiology. — This  variety  occurs  after  50  years 
of  age.  It  is  found  equally  among  the  sexes. 
Social  conditions  and  occupation  are  of  no  im- 
portance. 

The  exciting  causes  have  considerable  influ- 
ence—trauma, in  all  probability,  being  the  most 
important.  Trauma  of  the  shrunken  gum  pro- 
duces a  point  of  lowered  resistance,  and  as  a 
result  thereof  pathogenic  bacteria  of  the  mouth 
have  an  excellent  opportunity  for  development. 
At  the  site  of  the  trauma  a  focus  of  infection 
results  with  a  destruction  of  the  gum,  peridental 
membrane  and  the  alveolar  process.  The  chem- 
ical irritants,  namely  the  acids,  have  the  abil- 
ity to  produce  an  irritation  of  the  gum  with 
which  they  come  in  contact,  and  also  lower  the 
resistance  of  the  gum.  The  mechanical  irri- 
tants; namely  ill-fitting  plates,  bridges  and 
crowns,  also  produce  an  irritation  of  the  gum 
and  a  lowered  immunity  of  the  gum  with  which 
it  comes  in  contact.  The  thermal  irritants  b}' 
their  action  on  the  gum  bring  about  a  lowered 
resistance  which  may  or  may  not  terminate  in 
the  loss  of  the  gum  tissue  affected  by  them.  If 
the  pathogenic  bacteria  of  the  mouth  find  a 


VARIETIES  OP  PYORRHEA  47 

point  in  the  gum  tissue  around  a  tooth  which 
offers  them  protection  they  soon  commence  to 
multiply  and  by  their  growth  the  gum  is  de- 
stroyed at  this  point. 

Pathology.— The  onset  of  this  variety  is  in- 
sidious and  presents  gum  tissue  that  is  low  in 
resistance.  The  pockets  if  present  are  variable 
in  size  and  are  probably  the  result  of  one  of  the 
exciting  causes.  The  color  of  the  gum  varies 
from  a  normal  pink  to  a  deep  red.  The  con- 
sistency of  the  g-um  varies  from  a  normal  firm- 
ness to  variable  degrees  of  softness,  when  pal- 
pated. The  diseased  gum  may  or  may  not  be 
tender  on  pressure.  Massage  of  the  gum,  over 
a  pocket  brings  to  the  gingival  margin  an  exu- 
date which  on  microscopic  examination  is  found 
to  be  composed  of  pus  cells,  fibrin,  and  a  variety 
of  bacteria. 

Bacteriology. — The  most  common  organism 
associated  with  this  variety  is  the  staphylococ- 
cus pyogenes  fetidis.  The  staphylococcus  py- 
ogenes albus,  various  diplococci,  spirochceta 
refringens  and  leptothrix  buccalis  are  also 
found. 

Diagnosis. — The  diagnosis  of  the  senile  vari- 
ety is  made  on  the  age,  the  presence  of  loose 
teeth,  the  recession  of  the  gum,  the  presence  of 


48  PYORRHEA  ALVEOLARIS 

calcarious  deposits  on  the  exposed  portions  of 
the  roots  of  the  teeth  affected,  under  the  gingi- 
val margin,  and  some  times  at  a  considerable 
distance  from  the  necks  of  the  teeth  under  the 
gum.  There  may  or  may  not  be  pus  puckets 
present. 

Differential  Diagnosis.  —  The  only  variety 
that  this  is  likely  to  be  confused  with  is  the 
Presenile  Variety.  In  the  pre-senile  variety 
there  are  occasional  mild  exacerbations,  during 
which  the  gums  and  teeth  are  affected.  The  pa- 
tient is  younger  than  in  the  senile  variety.  In 
the  pre-senile  all  the  teeth  as  a  rule  are  pres- 
ent and  are  seldom  loose. 

Symptomatology.  —  The  senile  variety  is 
found  in  the  mouths  of  patients  past  50  years 
of  age.  Its  onset  is  insidious.  The  general 
health  of  the  patient  as  a  rule  is  good,  the  only 
complaint  being  that  the  remaining  teeth,  be- 
cause of  the  looseness,  cause  the  patient  con- 
siderable inconvenience.  The  teeth  may  or  may 
not  be  painful  on  occlusion.  There  may  or  may 
not  be  pus  present  around  the  teeth. 

Prognosis. — The  prognosis  is  bad.  If  it  is 
complicated  by  an  infection  the  prognosis  is 
good  as  far  as  the  infection  is  concerned,  but 
not  as  a  cure  of  the  disease. 


VARIETIES  OF  PYORRHEA  49 

Treatment. — A  stimulating  antiseptic  mouth 
wash  should  be  used  three  times  a  day,  and  the 
teeth  brushed  not  less  than  twice  a  day — morn- 
ing and  night.  Any  defects  in  the  diet  of  the 
patient  should  be  corrected  and  a  diet  pre- 
scribed by  the  family  physician  of  such  a  char- 
acter as  v/ill  improve  the  physical  condition. 
The  medicinal  treatment  should  be  such  as  will 
increase  the  system  physiologically  and  raise 
the  general  immunity  of  the  patient.  The  au- 
togenous BACTERIAL  VACCINES  whcu  givcn  with 
the  above  described  treatment  offer  good  re- 
sults as  far  as  the  infection  is  concerned,  but 
do  not  cure  the  disease.  Instrumentation  by  the 
dentist  is  a  valuable  adjunct  in  the  treatment  of 
this  variety  of  pyorrhea. 

Variety  Resulting  From  Trauma. 

Etiology. — This  variety  may  occur  at  any 
age  in  either  sex.  The  social  conditions  and 
occupations  are  of  no  consequence.  The  trauma 
may  be  the  result  of  instruments  used  by  the 
over-eager  dentist,  heroic  tooth  brushing,  the 
tooth  pick  and  match-chewing  habit,  excessive 
tooth  picking  after  meals,  a  blow  which  will 
loosen  the  tooth  in  its  socket,  and  very  hard 
brittle  food  substances  which  cut  the  gum  at 
the  gingival  margin  during  mastication.     Any 


50  PYORRHEA  ALVEOLARIS 

one  of  these  factors  occurring  in  the  mouth  of 
a  patient  with  a  local  lowered  immunity  with 
the  ever  present  pathogenic  bacteria  can  bring 
about  a  process  of  suppuration  which  can  re- 
sult in  a  destruction  of  the  gum,  peridental 
membrane,  and  alveolus.  The  tooth  or  teeth 
affected  become  so  loose  that  they  cause  the 
patient  great  inconvenience. 

Pathology. — The  onset  of  the  disease  is  sud- 
den and  the  tissues  surrounding  the  area  of 
trauma  are  markedly  inflamed  and  painful  on 
pressure.  If  infected,  slight  massage  causes  a 
considerable  amount  of  pus  to  appear  at  the 
gingival  margin.  As  a  rule  the  disease  is  local- 
ized to  one  tooth.  However  a  very  extensive 
process  may  be  observed  if  it  is  neglected  by 
the  patient.  In  the  later  stage  of  the  disease 
the  gum  is  a  very  bright  red  in  contrast  to  the 
normal  pink  color.  There  is  marked  swelling 
and  tenderness,  and  the  gum  is  very  tense  and 
hard.  The  entire  mucous  membrane  of  the 
mouth  may  be  affected  with  a  dribbling  of  sa- 
liva from  the  corners  of  the  mouth.  The 
breath  is  fetid.  The  teeth  may  feel  elongated 
and  are  painful  on  occlusion.  Very  little  tar- 
tar is  observed  in  this  variety. 

Bacteriology. — Any  of  the  pathogenic  organ- 
isms of  the  mouth  may  be  present. 


VARIETIES  OF  PYORRHEA  51 

Diagnosis. — The  diagnosis  is  made  on  the 
history  of  an  injury. 

Differential  Diagnosis. — This  variety  closely 
resembles  Vincent's  angina,  and  Is  differenti- 
ated from  it  by  a  microscopic  examination 
which  shows  the  spirillum  of  Vincent  and  fusi- 
form organisms. 

Symptomatology. — The  patient  states  that 
while  masticating  food  or  after  using  a  tooth 
pick  or  after  the  heroic  use  of  a  tooth  brush,  the 
gum  overlying  a  tooth  was  slightly  injured,  and 
after  twenty-four  hours  the  gum  felt  swollen, 
was  tender  to  the  touch,  and  bled  readily  when 
massaged  or  when  the  teeth  were  picked  with 
a  tooth  pick.  From  the  beginning  of  the  injury 
the  condition  gradually  became  worse  and  as  a 
result  of  the  inconvenience  of  the  gum  the  pa- 
tient calls  upon  the  dentist. 

Prognosis. — The  prognosis  in  this  variety  as 
to  a  cure  is  good. 

Treatment. — The  hygienic  treatment  should 
consist  of  an  antiseptic  and  astringent  mouth 
v/ash  and  the  application  of  a  cold  compress  to 
reduce  the  inflammation.  The  diet  should  be 
corrected  if  found  faulty.  If  on  examination 
the  patient  is  found  to  be  in  poor  health  sys- 
temic treatment  should  be    instituted    by    the 


52  PYORRHEA  ALVEOLARIS 

family  physician  and  an  autogenous  bacterial. 
VACCINE  made  if  a  process  of  suppuration  is 
present.  No  instrumentation  should  be  done 
until  after  the  patient  has  been  treated  sys- 
tematically and  with  the  vaccines. 

Variety  Eesulting  Feom  Chemical 
Irritants. 

Etiology. — This  variety  may  occur  at  any 
age,  or  in  either  sex.  Social  conditions  and  oc- 
cupation are  of  no  consequence.  Any  disease 
of  the  body  which  Impairs  the  normal  physio- 
logical processes  that  increase  or  decrease  the 
secretion  and  elimination  of  the  normal  acids, 
has  much  to  do  with  the  production  of  this  vari- 
ety, for  by  the  presence  of  these  products  in 
the  body  tissues  the  normal  resistance  of  the 
tissue  is  lowered  and  as  a  result  thereof  the 
natural  barriers  of  defense  are  impaired  and 
a  focus  of  suppuration  is  easily  established. 
The  inorganic  acids  when  coming  in  contact 
with  the  tissues  of  the  mouth,  by  their  escha- 
rotic  action  have  the  ability  to  bring  about  a 
lowered  resistance  and  thus  subject  the  tissues 
to  the  invasion  of  pathogenic  bacteria  with  de- 
struction of  them  in  variable  amount. 

The  disease,  when  the  result  of  an  inorganic 


VARIETIES  OF  PYORRHEA  53 

acid  or  escliarotic,  leaves  behind  such  evidence 
as  is  easily  identified,  namely  a  white  patch 
which  is  variable  in  size  depending  on  the 
amonnt  and  extent  of  the  chemical  irritant 
which  came  in  contact  with  the  tissue. 

Pathology. — The  gum  at  the  point  of  contact 
with  the  acid  is  white  in  color,  may  or  may  not 
be  swollen,  and  the  margin  of  the  patch  is  a 
bright  red  and  somewhat  painful.  On  remov- 
ing the  white  film  of  dead  mucous  membrane  a 
raw  bleeding  surface  is  exposed  which  is  very 
tender  to  the  touch.  In  the  presence  of  an  ex- 
cessive acid  saliva,  the  gum  around  all  the 
teeth  shows  marked  irritation  characterized  by 
a  bright  red  color,  swelling,  tenderness,  and  on 
pressure,  marked  sensitiveness  of  the  gum  at 
the  gingival  margin.  If  tartar  is  present  it  is 
generally  at  the  gingival  margin  varying  in 
color  from  pale  yellow  to  a  deep  yellow  and 
from  a  soft  chalky  to  a  hard  consistency. 

Bacteriology. — The  bacteria  present  in  this 
variety  may  be  any  of  the  pathogenic  bacteria 
found  in  the  mouth. 

Diagnosis. — The  diagnosis  is  made  on  the 
history  and  the  presence  of  the  white  eschar, 
which,  when  removed,  leaves  a  raw  bleeding 
surface  or  an  acid  saliva. 

Differential  Diagnosis. — This  variety  is  dif- 


54  PYORRHEA  ALVEOLAEIS  . 

ferentiated  from  Vincent's  angina  by  the  pres- 
ence of  the  spiriHum  of  Vincent  and  fusiforms, 
and  from  Lues  by  the  presence  of  the  spiro- 
chaeta  pallada. 

Symptomatology. — The  onset  is  sudden  with 
the  following  symptoms ;  soreness  of  the  gum  at 
the  point  with  which  they  come  in  contact  with 
the  acid,  inflammation  of  the  gum  around  the 
tooth  or  teeth  affected  by  contact  with  the  acid, 
or  by  the  presence  of  widespread  inflammation 
resulting  from  an  acid  saliva.  These  inconven- 
iences prevent  proper  mastication  of  the  food 
and  brushing  of  the  teeth. 

Treatment.- — -The  treatment  must  be  of  such 
a  character  as  will  be  soothing  to  the  gums  and 
antiseptic.  If  the  mouth  and  gums  are  badly 
burned  such  diet  should  be  recommended  as  will 
offer  least  irritation.  It  is  best  to  have  the 
family  physician  prescribe  the  diet  and  he 
should  also  look  after  the  general  treatment  if 
the  patient  is  not  in  good  health.  If  an  infec- 
tion is  present  it  should  be  treated  with  iodin, 
and  if  the  infection  does  respond  to  the  iodin 

an     AUTOGENOUS     BACTEKIAL     VACCINE     should     be 

made. 


varieties  of  pyorrhea  55 

Variety  Resulting  From  Mechanical, 
Irritants. 

Etiology. — This  variety  may  occur  in  either 
sex  at  any  age;  social  conditions  and  occupa- 
tion being  of  no  consequence. 

Pathology. — The  gum  and  teeth  are  markedly 
inflamed,  tender  to  the  touch  and  swollen.  The 
color  is  a  deep  red  in  contrast  to  the  normal 
pink  color.  Tartar  may  or  may  not  be  present 
on  the  exposed  portion  of  the  tooth  or  teeth 
affected,  but  if  present  it  varies  in  color  from 
a  pale  to  a  deep  yellow  and  from  a  soft  chalky 
to  a  hard  consistency.  As  a  rule  the  gum  is 
shrunken  a  great  deal  from  around  the  necks 
of  the  teeth,  and  the  teeth  affected  are  quite 
loose. 

Bacteriology. — The  bacteriology  varies.  In 
one  case  there  is  one  variety  of  organism,  in  the 
next  case  another  variety  predominates. 

Diagnosis. — The  diagnosis  of  the  mechanical 
variety  is  very  easy,  as  the  irritant  can  be  found 
on  examination  of  the  gum.  It  will  be  noticed 
that  a  bridge  or  plate  produces  the  pressure 
that  acts  as  the  irritant. 

Differential  Diagnosis. — Is  made  on  the  pres- 
ence of  a  mechanical  irritant. 


56  PYORRHEA  ALVEOLARIS 

Prognosis. — Good. 

Symptomatology.— TYiQ  onset  of  this  variety 
is  slow.  The  patient  complains  of  soreness  of 
the  gum  around  a  tooth  or  teeth  which  are  the 
abutments  of  a  bridge,  or  of  the  teeth  with 
which  the  plate  comes  in  contact.  The  soreness 
at  first  is  slight,  and  as  the  bridge  or  plate  is 
not  suspected  to  be  the  cause  it  is  not  discarded. 
The  longer  it  is  worn  the  worse  the  condition 
becomes.  Eventually  the  gums  swell  and  if  the 
plate  or  bridge  is  taken  out  of  the  mouth  it 
causes  great  pain  when  replaced.  On  examina- 
tion the  plate  is  found  to  be  ill-fitting  and  at  the 
point  of  pressure  swelling  occurs.  When  mas- 
saged pus  exudes  from  around  the  gingival 
margin  of  the  teeth  affected. 

Treatment. — The  patient  should  be  given  a 
mouth  wash  which  is  astringent  and  antiseptic. 
The  tooth  or  teeth  affected  in  many  instances 
are  very  loose  and  should  be  extracted.  If  the 
diet  is  incorrect  it  must  be  remedied  by  the  fam- 
ily physician.  If  the  patient  is  in  poor  health 
the  general  treatment  should  be  of  such  a  char- 
acter as  will  build  him  up  physically.  If  pus  is 
present  an  autogenous  bacterial  vaccine 
should  be  used  in  conjunction  with  the  drugs 
given. 


VARIETIES  OP  PYORRHEA  57 

Variety  Resulting  From  Thermal 
Irritants 

Etiology. — This  may  occur  at  any  age.  Age, 
sex,  social  conditions  and  occupation  are  of  lit- 
tle importance. 

Pathology. — The  onset  of  this  variety  is  sud- 
den. The  gum  is  a  dark  red  color  and  is  highly 
inflamed  and  painful.  Slightest  pressure  at 
the  point  of  injury  causes  a  thin  exudate  to  ap- 
pear at  the  gum  margin.  The  gum  may  be  soft 
or  firm  on  pressure.  The  injury  may  be  local- 
ized or  wide-spread.  The  entire  mucous  mem- 
brane of  the  mouth  is  at  this  time  affected. 

Bacteriology. — If  the  point  of  injury  becomes 
infected  a  variety  of  organisms  may  be  found 
present  in  the  early  stages,  but  if  the  disease  is 
one  of  long  standing  one  variety  predominates. 

Diagnosis.— T\\Q  diagnosis  is  made  on  the 
history  of  a  burn  resulting  from  very  hot  food 
or  drink. 

Differential  Diagnosis. — This  variety  is  dif- 
ferentiated from  the  other  varieties  by  the  color 
and  extreme  painfulness  of  the  gum,  and  the 
history. 

Symptomatology. — The  onset  of  the  thermal 
variety  is  sudden  and  progress  is  quite  rapid. 


58  PYORRHEA  ALVEGLARIS 

As  a  rule  the  disease  has  reached  the  maximum 
of  development  at  the  point  of  injury  after  24 
hours.  If  the  injury  is  one  of  considerable  ex- 
tent the  patient  is  greatly  inconvenienced.  The 
injured  gum  has  at  first  a  numb  feeling,  but 
after  a  few  hours  this  feeling  subsides  and  the 
gum  becomes  very  tender.  If  localized  and  un- 
infected the  gum  is  inflamed  and  of  a  dark  red 
color  in  contrast  to  the  normal  pink  of  the  ad- 
jacent gum. 

Prognosis. — Good. 

Treatment. — The  treatment  should  consist  of 
a  bland  antiseptic  mouth  wash.  The  general 
treatment  should  be  of  such  a  character  as  will 
build  up  the  patient  physically.  An  autoge- 
nous BACTEKiAL  VACCINE  shouM  bc  administered 
if  the  injured  gum  becomes  infected. 

Variety  Resulting  Feom  Bacteeiological, 
Ieeitants. 

Etiology. — The  bacteriological  irritants  may 
produce  pyorrhea  at  any  age.  Sex,  social  con- 
ditions and  occupation  are  of  little  importance. 

Patliology. — The  pathology  in  this  variety 
presents  the  gum  in  a  stage  of  inflammation, 
and  tenderness  on  slightest  palpation.  The 
color   of   the  gum   is    a   turgid   red,     and     on 


VARIETIES  OF  PYORRHEA  59 

slight  massage  bleeds  readily.  As  a  rule  the 
condition  is  not  confined  to  one  tooth,  but  many 
teeth  are  affected  and  in  some  instances  all  of 
the  teeth  of  the  upper  or  lower  jaw.  An  exam- 
ination of  the  exudate  taken  from  the  gum 
around  the  affected  tooth  shows  that  it  is  com- 
posed of  epithelium,  pus  cells,  and  a  variety  of 
bacteria,  with  one  variety  in  predominance, 
generally  the  staphylococcus  fetidis. 

Bacteriology. — The  bacteria  observed  in  a 
smear  of  this  variety  are  the  staphylococci, 
streptococci,  diplococci,  leptothrix  huccalis,  and 
the  spirochceta  refringens. 

Diagnosis. — The  diagnosis  is  made  on  the 
wide  turgescence  of  the  gum  at  the  gingival 
margin,  the  presence  of  pus  around  the  teeth, 
and  the  slow  onset  and  invasion  of  the  disease 
which  affects  one  tooth  after  another. 

Differential  Diagnosis. — It  is  differentiated 
from  the  other  varieties  by  the  turgescence 
of  the  gums,  the  gradual  invasion  of  the  approx- 
imate teeth,  and  the  extreme  tenderness  of  the 
gums. 

Symptomatology. — The  onset  is  very  slow, 
the  patient  stating  that  the  exact  time  of  com- 
mencement of  the  disease  is  not  known.  At  first 
there  is  a  feeling  of  irritation  of  the  gum  at  the 


60  PYORRHEA  ALVEOLARIS 

necks  of  the  teeth,  later  it  becomes  a  little  swol- 
len and  somewhat  tender.  This  process  con- 
tinues and  after  a  time  the  patient,  having 
failed  to  relieve  this  condition,  calls  on  the 
dentist  stating  that  the  gum  around  the  teeth 
is  exceedingly  tender  to  the  touch,  that  food 
cannot  be  masticated,  and  that  the  use  of  the 
tooth-brush  is  impossible. 

Prognosis. — Good. 

Treatment. — The  treatment  is  dependent  on 
the  absolute  cleanliness  of  the  mouth  and  teeth. 
An  astringent,  antiseptic  mouth  wash  is  of  first 
importance  and  should  be  used  every  two  hours 
at  the  beginning  of  the  treatment.  The  diet 
should  consist  of  wholesome  food  which  is  not 
hard  to  masticate  and  not  irritating  to  the  tis- 
sues of  the  mouth.  It  is  best  to  refer  the  pa- 
tient to  the  family  physician  for  the  diet.  The 
general  treatment  of  the  patient,  if  not  in  good 
health,  should  also  be  attended  to,  and  should 
be  of  such  a  character  which,  when  given  in  con- 
junction with  the     AUTOGENOUS    BACTERIAL    VAC- 

ciNEs,  will  assist  in  raising  the  immunity  of  the 
patient. 


CHAPTER  II. 
Technique  for  Making  a  Blood  Smear. 

The  technique  for  making  a  blood  smear  for 
a  differential  blood  count  is  difficult  for  the  be- 
ginner, but  with  a  little  practice  soon  becomes 
very  easy. 

The  points  commonly  selected  for  this  pur- 
pose are  the  lobe  of  the  ear  and  the  root  of  tlio 
nail  of  a  finger.  The  point  selected  should  be 
washed  with  a  piece  of  cotton  dipped  in  a  50  per 
cent  solution  of  alcohol.  After  a  few  minutes 
the  excess  of  alcohol  is  wiped  off  with  a  piece  of 
sterile  cotton.  If  the  lobe  of  the  ear  is  selected, 
it  is  grasped  firmly  between  the  thumb  and  the 
index  finger,  care  being  taken  not  to  touch  that 
portion  from  which  the  blood  is  to  be  taken.  A 
small  bistoury  or  hagadorn  needle  is  used  to 
make  the  puncture  in  the  sterile  portion  project- 
ing between  the  thumb  and  index  finger.  The 
first  drop  appearing  at  the  point  of  puncture  is 
removed  with  a  piece  of  sterile  cotton.  A  small 
drop  is  then  allowed  to  accumulate,  which  is 
brought    in    contact  with  a  clean  slide.     This 

61 


62  PYORRHEA  ALVEOLAEIS 

slide  is  then  placed  on  a  solid  place,  being  held 
firmly  by  the  index  finger  and  thumb  of  the  left 
hand.  A  clean  slide  is  held  between  the  index 
finger  and  the  thumb  of  the  right  hand.  The 
edge  of  this  slide  is  brought  in  contact  with  the 
droplet  of  blood.    By  a  forward  and  backward 


Fig.   I. — Position  for  making  a  blood  smear. 

motion  of  this  slide  the  blood  is  equally  distrib- 
uted between  the  edge  of  this  slide  and  the  sur- 
face of  the  slide  held  by  the  left  hand,  on  which 
the  permanent  blood  smear  is  to  be  made.  (Sec 
Fig.  I.) 

Technique  for  Staining  Slide. 

The  smear  having  been  made  it  should  be 
dried  as  quickly  as  possible  to  prevent  crena- 
tion  of  the  blood  corpuscles.  The  smear  is  then 
stained  with  Wright 's  stain,  the  slide  placed  on 


TECHNIQUE  FOR  MAKING  A  BLOOD  SMEAR  63 

a  staining  pot  and  about  3  cubic  centimeters  of 
the  stain  added  to  the  smear.  This  is  allowed 
to  remain  on  the  slide  from  one  to  one-and-a- 
half  minutes  and  distilled  water  is  added.  This 
distilled  water  is  poured  off,  and  the  smear 
thoroughly  washed  with  distilled  water  until  no 
color  comes  away.  The  slide  is  then  dried  and 
ready  for  examination. 

Differential  Blood  Count. 

By  a  differential  blood  count  is  meant  the 
counting  and  classification  of  the  white  blood 
corpuscles  morphologically  and  tinctorially, 
contained  in  the  blood  smear  on  the  slide. 

One  hundred  cells  are  counted  and  each  vari- 
ety is  recorded  as  counted.  This  having  been 
done,  the  number  of  cells  counted  after  each 
variety  is  added,  thus  obtaining  the  percentage. 
A  very  convenient  method  which  is  used  for  this 
step  is  as  follows : 
Polymorphonuclear  Neutraphylic  ////  Z///-  •  10% 

Large  Lymphocytes  UH  IHl  H 12% 

Small  Lymphocytes  //// 4% 

Eosinophiles  / 1% 

Transitionals  /. .  . 1% 

Basket  Cells  //// 4% 

NOTE. — This   is   not   a   complete    count,   but   shows   how    the    count    is 
recorded  and  reckoned. 


64  PYORRHEA  ALVEOLARIS 

In  persons  affected  by  pyorrhea  the  differ- 
ential blood  count  shows  a  marked  reduction  of 
the  polymorphonuclear  neutraphylic  leucocytes, 
small  lymphocytes,  and  an  increase  of  the 
number  of  the  large  lymphocytes  and  basket 
cells.  This  condition  is  known  hematologically 
as  a  lymphocytosis. 

The  large  lymphocytes  vary  tinctorially  from 
a  pale  blue  stained  nucleus  to  a  reddish-violet, 
stained  nucleus.  The  cytoplasm  like  the  nucleus 
is  stained  from  a  pale  blue  to  a  reddish-violet. 

The  blood  count  is  a  very  necessary  part  of 
the  technique  in  making  a  diagnosis  in  conjunc- 
tion with  the  other  examinations  made.  There- 
fore it  should  be  made  a  rule  that,  in  every  case 
presented  for  examination  and  diagnosis,  a  dif- 
ferential blood  count  should  and  must  be  made. 

Technique  foe  Making  Weight's  Stain. 

Dissolve  0.5  grams  of  sodium  bicarbonate  in 
100  c.c.  of  distilled  water.  When  the  sodium 
bicarbonate  is  dissolved,  add  to  this  solution 
one  gram  of  Griibler's  methylene  blue  (B.X.). 
This  solution  is  then  placed  in  a  steam  sterilizer 
for  one  hour,  the  temperature  of  which  is  100° 
C.  It  is  allowed  to  cool,  after  which  a  solution 
of  yellowish  aqueous  eosin  is  added — one  gram 


TECHNIQUE  FOR  MAKING  A  BLOOD  SMEAR 


65 


to  1,000  c.c.  of  distilled  water.  When  about 
500  c.c.  of  the  eosin  solution  has  been  added,  it 
is   noted   that   the   color   of   the    solution   has 


Fig.  II. — Ai-nold  steam  sterilizer.  This  apparatus  is  made 
throughout  of  copper,  with  double  walls  and  doors,  so  that  the 
sterilizing-  chamber  is  surrounded  on  all  sides  with  a  jacket  of 
steam.  An  unvarying  temperature  of  100°  C.  can  be  indefinitely 
maintained  in  the  sterilizing  chamber  without  any  attention. 
(Courtesy  Ernst  Leits,  New   York.) 


changed  to  a  purple  and  the  skum  present  has 
a  metal  sheen,  also  that  there  is  commencing  to 
appear  a  precipitate  which  is  of  a  bluish-black 


66  PYORRHEA  ALVEOLARIS 

color.  After  the  precipitate  has  appeared  the 
eosin  solution  is  added  gradually,  and  the  quan- 
tity of  the  precipitate  noted  from  time  to  time 
on  a  piece  of  clean  white  paper.  As  soon  as  the 
added  eosin  no  longer  causes  an  increase  of  the 
precipitate,  the  precipitate  is  then  separated 
from  the  filtrate  by  filtering.  After  the  filter- 
ing process  has  been  completed,  the  precipitate 
which  has  collected  on  the  filter  paper  is  al- 
lowed to  dry.  When  a  solution  of  the  powder 
is  desired  for  staining,  0.3  grams  of  the  powder 
is  dissolved  in  100  c.c.  of  methyl  alcohol  (C.P.). 


CHAPTER  III. 
Technique  for  Making  Stains. 

Technique  foe  Staining  a  Smear  of  Bacteria. 

The  film  of  exudate  taken  from  a  pus  pocket 
at  the  neck  of  the  tooth  with  a  platinum  loop  is 
smeared  as  thin  as  possible  on  a  clean  slide. 
The  smear  is  then  allowed  to  dry  and  after  dry- 
ing is  fixed  on  the  slide  by  passing  the  slide 
through  a  gas  flame  three  or  four  times.  The 
film  is  then  covered  with  a  methylene  blue  stain 
which  is  allowed  to  remain  on  the  slide  for  one 
minute.  The  stain  is  poured  off  and  the  excess 
amount  of  stain  is  washed  off  with  distilled 
water.  After  the  slide  is  dry  it  is  then  ready  for 
examination  under  the  microscope. 

When  Gram's  stain  is  used  on  the  specimen 
the  technique  is  as  follows : 

The  smear  is  made  in  the  same  manner  as  de- 
scribed above.  The  specimen  is  covered  with 
gentian- violet  and  set  aside  for  5  minutes.  Theu 
the  gentian-violet  is  poured  off  and  the  speci- 
men is  covered  with  Gram's  iodin,  which  is  al- 
lowed to  remain  on  the  slide  for    15   minutes. 

67 


68  PYORRHEA  ALVEOLARIS 

The  Gram's  iodin  is  then  poured  off  and  95  per 
cent  alcohol  is  added  to  the  specimen  and  the 
specimen  washed  with  it  until  no  more  color 
comes  away.  The  specimen  is  then  counter- 
stained  with  Bismarck-brown  for  1  to  3  min- 
utes. After  this  is  poured  off  the  slide  is 
washed  and  dried  and  is  ready  for  examination. 

Technique  for  Making  Carbol  Gentian. 

To  100  c.c.  of  an  aqueous  carbolic  acid  solu- 
tion add  30  c.c.  of  a  saturated  alcoholic  solution 
of  gentian-violet.  Filter  and  set  aside  for  24 
hours.    The  solution  is  then  ready  for  use. 

Technique  for  Making  Geam^s  Iodin  Solution. 

Dissolve  one  gram  of  iodin  and  two  grams  of 
potassium  iodid  in  10  c.c.  of  95  per  cent  alcohol. 
As  soon  as  the  iodin  and  the  potassium  iodid 
are  dissolved,  add  to  this  solution  300  c.c.  of 
distilled  water.  Set  aside  for  24  hours.  Filter 
into  a  clean  bottle  and  the. solution  is  ready  for 
use. 

Technique  for  Making  Bismarck-Brown 

Solution. 
This  stain  is  an  excellent   one   for    counter- 
staining  bacteria  by  Gram's  method  and  is  made 
as  follows: 


TECHNIQUE  FOR  MAKING  STAINS  69 

Dissolve  0.5  grams  of  Bismarck-brown  in  5 
c.c.  of  95  per  cent  alcohol.  As  soon  as  the 
powder  is  dissolved  add  to  the  solution  100  c.c. 
of  a  2  per  cent  aqueous  carbolic  acid  solution. 
This  solution  is  set  aside  for  24  hours,  after 
which  it  is  filtered  and  ready  for  use. 

Technique  for  Making  Methylene  Blue. 

Dissolve  5  grams  of  methylene  blue  in  50  c.c. 
of  95  per  cent  alcohol.  Set  this  solution  aside 
for  2  days.  To  100  c.c.  of  distilled  water  add 
30  c.c.  of  the  alcoholic  solution  of  the  methy- 
lene blue.  Set  aside  for  24  hours,  filter,  and 
the  solution  is  ready  for  use. 

Technique  for  Making  Loeffler's  Methylene 
Blue. 

To  100  c.c.  of  a  1 :10,000  solution  of  potassi- 
um hydroxide  add  30  c.c.  of  an  alcoholic  solu- 
tion of  methylene  blue.  Set  the  solution  aside 
for  24  hours  and  filter,  after  which  it  is  ready 
for  use. 


CHAPTEE  ly. 

Technique  for  Making  Culture  Media. 

To  the  beginner  the  technique  for  making 
agar  is  a  very  hard  task.  The  author  (thanks 
to  his  teacher,  Dr.  M.  A.  Barber,  formerly  of 
the  University  of  Kansas,  who  is  a  master  in 
the  art  of  making  agar)  was  so  thoroughly  im- 
pressed that  he  wishes  to  do  the  same  for  the 
reader  of  this  little  monograph. 

PEEPAEATION   OF  AGAR. 

The  first  step  is  the  preparation  of  the  agar 
which  is  as  follows : 

The  agar  is  broken  up  into  small  threads  ap- 
proximately one  inch  in  length.  15  grams  of 
agar  prepared  in  this  manner  are  placed  in  a 
flask  which  contains  500  c.c.  of  distilled  water. 
The  flask  is  then  stoppered  and  set  aside  for  3 
days. 

The  second  step  is  the  preparation  of  the 
meat  infusion  and  is  as  follows : 

One  pound  of  lean  beef  is  chopped  up  very 
fine  and  placed  in  a  flask  which  contains  500  c.c. 

70 


TECHNIQUE  FOR  MAKING  CULTURE  MEDIA  71 


Fig.  III. — Autoclav.     This  apparatus  is  for  sterilization  under 
steam  pressure.     (Courtesy  Ernst  Leitz,  New  York.) 


72  PYORRHEA  ALVEOLARIS 

of  distilled  water.  The  flask  containing  tlie 
meat  infusion  is  then  placed  in  the  refrigerator 
for  24  hours. 

The  next  step  is  the  autoclaving  of  the  agar 
at  about  12  pounds  for  one  hour.  While  the 
agar  is  autoclaving,  the  meat  is  strained 
through  a  clean  towel  and  the  quantity  after 
straining  brought  up  to  500  c.c.  Add  to  the 
meat  infusion  5  grams  of  salt  and  10  grams  of 
peptone  (Witte).  These  substances  having 
been  added  to  the  meat  infusion,  it  is  placed  on 
a  hot  plate  and  the  peptone  and  salt  are  grad- 
ually dissolved.  Do  not  allow  the  temperature 
of  the  meat  infusion  to  rise  above  39°  C. 

.  The  agar  is  now  removed  from  the  autoclav 
and  cooled  to  39°  C.  The  meat  infusion  is  again 
placed  on  the  hot  plate  and  the  temperature 
gradually  raised  to  the  boiling  point,  and  at  the 
same  time  the  agar  is  added,  stirring  the  mix- 
ture vigorously  until  all  of  the  agar  has  been 
added.  The  mixture  is  then  thoroughly  boiled, 
after  which  it  is  filtered  through  cotton  in  a  fun- 
nel (through  which  boiling  water  has  been  pre- 
viously passed)  into  a  clean  flask. 

As  soon  as  all  of  the  agar  has  passed  through 
the  filter  two  samples  of  5  c.c.  each  are  taken 
from  the  agar  and  are  placed  in  a  small  beaker 


TECHNIQUE  FOR  MAKING  CULTURE  MEDIA 


73 


A  — 


Fig.   IV. — Burette-bottle   containing  NaOH    (N/10),   and  wood 
holder  for  burette. 


A.  Rubber  hose  for  making  suction. 

B.  Wood  clamp  for  holding  burette. 
G.  Burette. 

D.  Rubber  hose. 

E.  Clip  for  controlling  NaOH. 

F.  Glass  nozzle. 

G.  Glass  tube  from  bottle  to  burette. 

H.  Glass  chamber  containing  lime  through  which  air  enters 
bottle. 


74  PrOERHEA  ALVEOLARIS 

for  titration.  The  flask  of  agar  is  again  placed 
in  a  steam  sterilizer  for  one  hour.  While  the 
flask  of  agar  is  in  the  steam  sterilizer  the  titra- 
tion of  the  agar  may  be  done. 

The  technique  for  titration  is  as  follows : 
To  the  5  c.c.  of  agar  placed  in  each  beaker  is 
added  45  c.c»  of  distilled  water  and  the  beaker 
is  placed  in  a  water  bath  and  boiled  vigorously. 
The  object  of  this  step  is  to  rid  the  mixture  of 
as  much  carbondioxide  as  possible.  To  the  mix- 
ture which  has  been  boiled  is  added  0.5  to  1  c.c. 
of  a  1  per  cent  alcoholic  solution  of  phenol- 
phthalein,  which  is  the  indicator.  The  titration 
is  then  commenced.  Before  continuing  this 
step  of  the  technique,  it  will  perhaps  be  best  to 
describe  the  burette.  This  instrument  is  a  long 
glass  tube  graduated  into  tenths  of  a  cubic  cen- 
timeter. If  the  substance  to  be  titrated  is  sus- 
pected of  containing  an  acid,  the  burette  is 
filled  with  an  N/IO  solution  of  sodium  hydrox- 
ide, which  means  that  one-tenth  of  the  sum  of  the 
atomic  weight  of  the  sodium  hydroxide  is  added 
to  the  liter.  Thus  in  this  case  the  sodium  hydrox- 
ide is  composed  of  sodium,  hydrogen  and  oxy- 
gen. The  sum  of  the  atomic  weight  of  these  sub- 
stances is  40.  Hence,  to  make  a  normal  solu- 
tion 52.92  grams  of  sodium  hydroxide  are  added 


TECHNIQUE  FOR  MAKING  CULTURE  MEDIA  75 

to  the  liter,  and  to  an  N/10  solution  one-tentli 
of  the  amount  of  the  sum  of  the  atomic  weights, 
which  is  5.292  to  the  liter  of  distilled  water. 
This  solution  is  then  titrated  against  an  N/10 
solution  of  hydrochloric  acid.  One  c.c.  of  the 
hydrochloric  acid  is  placed  in  a  small  beaker  to 
which  distilled  water  is  added.  The  solution  is 
boiled,  and  0.5  c.c.  of  phenolphthalein  is  added, 
which  is  the  indicator.  The  NaOH  solution  is 
then  allowed  to  slowly  run  into  the  beaker  con- 
taining the  acid.  As  soon  as  the  first  color  ap- 
pears a  reading  is  made  on  the  burette.  The 
next  step  is  the  subtraction  of  this  reading 
from  the  original  reading,  and  the  result  should 
show  that  1  c.c.  of  the  NaOH  will  neutralize 
1  c.c.  of  the  HCl.  If  this  end  reaction  occurs 
then  the  N/10  NaOH  is  correct.  If  it  is  short 
of  or  over  this  reaction  more  NaOH  or  water 
must  be  added. 

> 

For  example : 

First  reading 10.0 

Second  reading 10.9 

Subtracting 

10.9 
10.0 

00.9 


76  PYORRHEA  ALVEOLAKIS 

Therefore  more  of  the  NaOH  would  have  to 

be  added  to  the  solution. 

Again,  for  example,  suppose  agar  is  being 
titrated : 

First  reading ,  10 . 0 

Second  reading  11 . 9 

Subtracting 

11.9 
11.0 


00.9x2=1.8  per  cent  acidity. 

If  a  neutral  solution  is  desired  18  c.c.  of 
NaOH  (N)  is  added. 

After  the  agar  has  been  in  the  sterilizer  for 
one  hour,  it  is  removed  and  another  titration  is 
made  to  determine  if  the  correction  made  is 
correct.  If  not,  NaOH  is  again  added.  The  agar 
and  broth  which  give  the  best  results  culturally 
are  0.8  per  cent  acid.  Hence,  therefore  add 
10  c.c.  of  the  NaOH  to  the  agar  or  broth. 

PEEPAEATIOIsr  OF  BKOTH. 

One  pound  of  lean  beef  or  veal  is  chopped 
very  fine  and  placed  in  a  flask,  after  which  500 
c.c.  of  distilled  water  is  added.    The  meat  in- 


TECHNIQUE  FOR  MAKING  CULTURE  MEDIA  77 

fusion  is  placed  in  a  refrigerator  for  24  hours, 
and  then  strained  through  a  clean  towel.  To 
the  infusion  thus  obtained  5  grams  of  salt  and 
10  grams  of  peptone  are  added.  The  infusion 
is  brought  up  to  1,000  c.c.  and  poured  into  a 
granite  vessel  and  brought  to  39°  C,  at  whicli 
temperature  it  is  held  until  the  peptone  is  dis- 
solved. As  soon  as  the  peptone  is  dissolved,  it 
is  boiled  vigorously  for  10  minutes  and  then 
filtered  in  the  same  manner  as  the  agar. 

Technique  for  Tubing  and  Sterilization  of 
Culture  Media. 

Select  heavy  walled  glass  tubes,  the  content 
of  which  can  vary  depending  on  the  quantity 
desired.  The  cotton  plugs  with  which  the  tubes 
are  stoppered  should  be  of  the  best  absorbent 
cotton.  The  cotton  stopper  of  the  tube  is  with- 
drawn and  held  between  the  index  and  second 
fingers  of  the  left  hand.  Place  in  each  tube  the 
desired  quantity  of  the  culture  media  after 
which  the  stopper  is  again  placed  in  the  tube 
and  the  tube  placed  in  a  basket.  The  tubes 
having  been  filled  are  placed  in  the  autoclav 
or  the  steam  sterilizer.  If  placed  in  the  steam 
sterilizer  they  are  kept  there  for  one  hour.    If 


78  PYORRHEA  ALVEOLAEIS 

placed  in  the  autoclav  tlie  pressure  of  the  auto- 
clav  is  raised  to  12  pounds,  after  which  it  is 
allowed  to  cool  and  the  tubes  removed.  If  the 
steam  sterilizer  is  used  the  tubes  must  be  steril- 
ized for  3  consecutive  days,  but  if  the  autoclav 
is  used  one  sterilization  is  sufficient.  The  tubes 
are  ready  for  use  after  being  sterilized. 


CHAPTER  V. 

Bacteriology. 

The  following  bacteria  are  most  commonly 
observed  in  pyorrhea : 

I.  Staphylococcus  Pyogenes  Albus. 

II.  Staphylococcus  Pyogenes  Aureus. 

III.  Staphylococcus  Pyogenes  Citrous. 

IV.  Staphylococcus  Pyogenes  Fetidis. 
V.  Streptococcus  Pyogenes. 

VI.  Bacillus  Pyocyaneous. 

VII.  Diplococcus  Pneumonia. 

VIII.  Leptothrix  Buccalis. 

IX.  Spirochseta  Refringens. 

A  complete  description  of  the  above  bacteria 
is  given  in  the  following  pages : 

Staphylococcus  Pyogenes  Albus. 

This  organism  is  non-motile,  non-flagellate, 
and  does  not  form  spores.  It  liquifies  gelatin, 
is  non-chromogenic,  is  aerobic  or  facultative  and 
anasrobic.  It  stains  readily  with  methylene  blue 
and  Gram's  method. 

This  organism  is  variably  pathogenic,  for  ex- 
periment has  shown  that  when  guinea-pigs  or 


80    ■  PYORRHEA  ALVEOLARIS 

rabbits  are  inoculated  with  a  culture  a  localized 
abscess  develops.  But  if  latbal  doses  are  in- 
jected directly  into  the  blood-stream  an  occa- 
sional septicaemia  develops,  and  Avhen  it  does 
small  abscesses  are  found  in  the  capillaries  and 
the  kidneys. 

Morphology. — This  organism  morphologic- 
ally measures  0.7  microns  in  diameter.  It  is 
hemispherical  in  shape,  and  forms  groups  in  an 
irregular  manner.  The  most  common  group- 
ing is  likened  to  a  bunch  of  grapes. 

Isolation. — Isolation  is  readily  made  as  fol- 
lows : 

The  first  step  is  the  sterilization  of  the  Petri 
dish.  Before  receiving  the  culture  media  the 
Petri  dish  should  be  placed  in  a  hot  air  steril- 
izer, the  temperature  of  which  is  gradually 
raised  until  it  reaches  250  to  300  degrees  C. 
This  temperature  is  held  for  20  to  30  minutes, 
after  which  the  sterilizer  is  allowed  to  cool,  and 
the  Petri  dish  should  be  removed  as  soon  as  it 
can  be  handled.  The  culture  media  of  agar- 
agar  is  then  liquified  and  placed  in  the  Petri 
dish.  The  culture  media  is  inoculated  as  soon 
as  it  has  solidified,  after  which  the  Petri  dish 
is  inverted  and  placed  in  the  incubator.  The 
second  step  is  to  place  in  the  Petri  dish  5  to  10 


BACTERIOLOGY 


81 


Fig.  V. — Petri  dish. 


Pig-.  VI. — Hot  air  sterilizer.    (Courtesy  Ernst  Letts,  New  York.) 


82  PYORRHEA  ALVEOLARIS 

c.c.  of  agar  or  gelatin.  The  lid  is  then  placed 
quickly  over  the  dish  and  the  agar  or  gelatin  is 
allowed  to  cool.  After  the  agar  or  gelatin  has 
cooled  a  smear  from  the  pus  or  a  test  tube  is 
made  by  rubbing  a  platinum  loop  over  the  sur- 
face of  the  culture  media.  The  Petri  dish  is 
then  inverted  and  placed  in  the  incubator.  At 
the  end  of  24  hours  the  colonies  appear  on  the 
surface  of  the  culture  media  as  small  white 
points,  which  extend  rapidly  over  the  surface 
of  it.  In  the  planting  of  the  pus  or  the  culture 
from  a  tube  a  group  of  organisms  are  some- 
times planted  below  the  surface  of  the  culture 
media.  If  this  is  the  case,  it  is  noted  after  24 
hours  that  at  the  point  where  this  has  occurred 
there  is  liquifaction,  and  the  growth  invading 
the  culture  media  comes  to  the  surface. 

Growth  on  Agar-Agar. — On  agar  the  organ- 
ism grows  along  the  entire  line  of  inoculation, 
appearing  moist  on  its  surface  and  is  well  cir- 
cumscribed.   The  color  is  white. 

Growth  on  Potato. — The  growth  on  potato  is 
luxuriant.  It  is  shiney,  moist,  and  white  in 
color. 

Growth  on  Bouillon. — In  bouillon  the  growth 
produces  a  diffuse  cloudiness  with  a  whitish 
sediment  in  the  bottom  of  the  tube. 


bacteriology  83 

Staphylococcus  Pyogenes  Aureus. 

This  variety  of  staphylococcus  is  not  widely 
distributed  in  nature.  It  does  not  live  a  sapro- 
phytic existence.  It  is  found  in  man  and  the 
lower  animals.  The  organism  is  occasionally 
present  in  the  dust  of  houses  and  hospitals. 
Its  most  common  habitat  is  on  the  skin  and  the 
mucous  membrane  of  the  mouth,  eyes  and  nose 
of  man. 

Morphology.  —  Morphologically  this  organ- 
ism is  like  the  staphylococcus  pyogenes  albus. 

Staining. — Stains  readily  by  methylene  blue 
and  by  Gram's  method. 

Isolation. — The  isolation  is  accomplished  as 
described  for  the  staphylococcus  albus.  The 
colonies  which  appear  after  inoculation  of  a 
Petri  dish  after  36  to  48  hours  are  of  a  golden 
color.  If  any  of  the  organisms  are  planted  be- 
low the  surface  of  the  culture  media  they  will 
liquify  it. 

Growth  on  Agar. — The  growth  on  agar  is 
moist,  shining  and  circumscribed,  and  has  a 
golden  color. 

Groivth  on  Potato. — The  growth  on  potato  is 
luxuriant,  is  moist  and  shining,  and  has  a  golden 
color. 


84  PYORRHEA  ALVEOLARIS 

Growth  in  Bouillon. — When  planted  in  bou- 
illon the  growth  of  this  organism  causes  a  dif- 
fuse cloudiness  with  a  variable  amount  of  pre- 
cipitate in  the  bottom  of  the  tube. 

Growth  in  Milk. — If  planted  in  milk  coagula- 
tion occurs  which  afterwards  is  followed  by  di- 
gestion of  the  casein. 

Pathogenesis. — The  pathogenesis  has  been 
proven  by  experiment  to  be  deadly.  Simple 
subcutaneous  introduction  of  the  organism  will 
produce  an  abscess  which  in  some  instances  has 
proven  fatal.  The  most  common  avenues  are 
abrasions  of  the  skin  or  mucous  membrane,  pro- 
tected places  such  as  the  crypts  of  the  tonsil, 
and  folds  of  mucous  membrane.  This  organ- 
ism is  at  all  times  present  in  the  mouth  and  is 
ready  to  commence  its  propagation  when  the 
resistance  of  the  tissue  is  below  normal. 

Toxins. — The  toxic  substances  were  first 
noted  by  Leber  in  1886.  He  observed  that  a 
culture  of  staphylococci,  when  treated  with  al- 
cohol, produced  a  crystalline  body  which  was 
soluble  in  alcohol  and  in  ether,  and  slightly  sol- 
uble in  water.  Leber  named  this  substance 
phlogosin.  Van  Der  Velde  in  his  work  found 
that  the  staphylococci  possess  metabolic  prod- 
ucts   that   are    destructive  to  leucocytes.     He 


BACTERIOLOGY  85 

states  that  the  action  of  these  products  inhibits 
the  ameboid  movement  of  the  leucocytes.  In 
addition  to  the  inhibitary  action  of  the  leuco- 
cytes, they  cause  the  leucocytes  to  become  spher- 
ical in  shape  and  to  gradually  lose  their  con- 
tents. To  the  substance  which  thus  affects  the 
leucocytes,  Van  Der  Velde  gave  the  name  of  leu- 
cocydin.  Kraus  in  his  work  on  this  organism 
observed  that  the  action  of  the  products  of  the 
staphylococci  were  hemolytic  and  that  by  this 
action  they  destroyed  red  blood  corpuscles. 
Neisser  and  Wechelsberg  confirmed  the  obser- 
vations of  Kraus  and  they  gave  to  this  sub- 
stance the  name  of  staphylosin. 

Staphylococcus  Pyogenes  Citeeus. 

This  variety  of  staphylococcus  is  morpholog- 
ically and  culturally  like  the  two  preceding  va- 
rieties. It  resembles  the  two  preceding  varie- 
ties so  closely  that  it  can  only  be  differentiated 
from  them  culturally.  After  24  hours  this  or- 
ganism culturally  is  a  rich  lemon  color. 

Staphylococcus  Pyogeintes  Fetidis. 

This  organism  is  found  almost  constantly 
present  in  the  mouth  of  man  around  the  teeth, 
in  the  pockets  around  the  diseased  roots  of  the 


86  PYORRHEA  ALVEOLAEIS 

teeth,  and  under  the  gingival  margin  of  the 
gum  around  healthy  teeth. 

Morphology. — Morphologically  like  the  other 
staphylococci. 

Staining. — Stains  readily  with  the  anilin 
stains  and  by  Grram's  method. 

Isolation. — Is  isolated  in  the  same  manner  as 
any  of  the  other  staphylococci. 

Groivth  on  Agar. — On  agar  it  grows  readily, 
and  culturally  looks  like  the  staphylococcus 
pyogenes  albus,  but  is  differentiated  from  it  by 
the  foul  odor  which  it  produces  when  growing 
on  agar. 

Groivth  on  Potato. — G-rows  readily  on  potato. 

Growth  in  Bouillon. — Grows  readily  in  Bou- 
illon, producing  a  marked  cloudiness  and  foul 
odor. 

Growth  in  Milk. — If  planted  in  milk  this  or- 
ganism first  produces  a  coagulation,  which  is 
later  followed  by  a  digestion  of  the  casein. 

Pathogenesis. — The  pathogenesis  is  at  the 
present  being  worked  on  by  the  author.  At  this 
time  the  findings  are  not  clear  and  as  a  result 
he  does  not  wish  to  commit  himself. 


BACTERIOLOGY  O  i 

Steeptococcus  Pyogenes. 

This  organism  is  non-motile,  does  not  pos- 
sess flagella,  does  not  form  spores,  will  not 
liquify  gelatin  or  agar,  is  aerobic  and  faculta- 
tive anaerobe.  It  is  spherical  in  shape  and  is 
infectious  for  man  and  the  lower  animals.  By 
their  division  threads  are  formed. 

Morphology. — It  is  spherical  in  shape,  vari- 
able in  size  from  0.4  to  1  micron  in  diameter, 
and  is  constantly  present  in  chains  or  pairs. 

Staining. — Stains  with  anilin  dyes  and  by 
Gram's  method. 

Isolation. — The  isolation  is  the  same  as  de- 
scribed for  the  staphylococcus  albus.  The  col- 
onies which  appear  after  inoculation  of  a  Petri 
dish  are  of  a  yellowish  color  after  36  to  48  hours. 
The  organism  if  planted  below  the  surface  of 
solid  cluture  media  does  not  liquify  it.  It  can 
be  isolated  from  pus  by  one  of  two  methods — 
by  the  plating  technique,  or  by  inoculating  a 
mouse  or  guinea-pig. 

Growth  on  Agar. — On  agar  an  exceedingly 
delicate  growth  develops  along  the  line  of  in- 
oculation, and  is  composed  of  very  small  color- 
less transparent  colonies,  which  do  not  coalesce. 

Growth  on  Potato. — Grows  poorly  on  potato. 


88  PYORRHEA  ALVEOLARIS 

Growth  in  Bouillon. — Grrows  very  slowly  in 
bouillon,  and  if  planted  in  bonillon  grows  best 
if  slightly  neutral  or  acid. 

Growth  in  Milk. — Grows  quite  readily  in  milk 
and  digests  the  casein. 

Growth  on  Blood  Serum  Agar. — The  growth 
on  blood  serum  agar  resembles  the  growth  on 
plain  agar.  This  media  is  not  affected  by  their 
growtlt. 

Growth  on  Gelatin. — The  colonies  on  gelatin 
are  small,  colorless,  and  translucent.  Micro- 
scopically they  appear  irregular  and  granular 
after  24  to  48  hours,  and  by  transmitted  light 
have  a  light-yellow  color. 

Pathogenesis. — The  virulence  of  this  organ- 
ism (according  to  Marmorek)  can  be  greatly  in- 
creased by  rapid  passage  through  rabbits  and 
maintained  by  the  use  of  culture  media  com- 
posed of  three  parts  of  human  blood  serum  and 
one  part  of  bouillon.  By  continuing  this  tech- 
nique he  was  able  to  attenuate  the  virulence  of 
this  organism  to  such  a  degree  that  a  one- 
hundred  thousand  millionth  of  one  cubic  centi- 
meter when  injected  into  the  ear  of  a  rabbit  was 
fatal. 

Toxic  Products. — The  toxic  products  of  the 
streptococci  are  not  well  known.    The  action  of 


BACTERIOLOGY  89 

hypodermic  injections  of  cultures  from  differ- 
ent sources  varies  greatly.  Cultures  which 
have  been  killed  by  sterilization  produce  a  more 
marked  reaction  than  does  the  filtrate. 

Bacillus  Pyocyaneous. 

This  organism  is  a  minute  slender  bacillus. 
It  is  motile,  flagellated,  does  not  form  spores; 
is  chromogenic,  pathogenic,  aerobic,  or  a  facu- 
lative  anaerobe,  and  liquifies  agar  and  gelatin. 

Morphology.—M.oY-phologiGBllj  it  is  a  short, 
slender  rod  with  rounded  ends  measuring  0.3 
to  2  microns  in  length,  often  seen  in  chains  of 
four  to  six.  The  only  organism  which  this  one 
resembles  is  the  hacillus  fluorescens  liquefaci- 
ens. 

Staining. — Stains  readily  with  any  of  the 
anilin  stains,  but  not  by  G-ram's  method. 

Isolation. — The  isolation  is  easily  accom- 
plished by  plating  the  pus.  The  superficial  col- 
onies growing  on  agar  or  gelatin  in  the  Petri 
dish  are  small,  irregular,  and  greenish  in  color. 
After  24  to  48  hours  there  is  distinct  fluores- 
cence of  the  culture  media.  When  examined 
microscopically  the  colonies  are  found  to  be 
round,  coarsely  granular,  with  serated  fila- 
mentous border.     The  centers  of  the  colonies 


90  PYORRHEA  ALVEOLAKIS 

are  distinctly  green,  while  the  borders  are  a 
pale  green.  As  the  process  of  liquifaction  of  the 
culture  media  progresses  the  colonies  sink 
into  it. 

Growth  on  Agar. — The  plant  on  agar  grows 
readily  along  the  line  of  inoculation.  After  24 
hours  the  color  of  the  plant  is  a  bright  green 
and  is  in  all  likelihood  dependent  on  a  soluble 
pigment  known  as  fluorescein,  which  saturates 
the  culture  media,  giving  it  the  characteristic 
fluorescent  appearance.  If  the  culture  media 
is  high  in  peptone,  the  color  changes  to  a  deep 
blue  green,  dark  blue  or  a  reddish-brown  with 
the  age  of  the  culture.  These  characteristic 
changes  of  color  are  the  result  of  another  sub- 
stance, pyocyanin. 

Growth  on  Potato. — The  growth  on  potato  is 
very  luxuriant  and  varies  in  color  from  a  green 
to  a  brown. 

Growth  in  Bouillon. — ^In  bouillon  this  organ- 
ism produces  a  diffuse  cloudiness  and  a  pellicle 
is  observed  on  its  surface. 

Growth  in  Milk. — It  grows  readily  in  milk, 
which  is  first  coagulated  and  later  peptonized. 
The  reaction  of  the  milk  a  short  time  after  in- 
oculation becomes  acid. 

Pathogenesis. — This  organism  is  found  in  the 


BACTERIOLOGY  91 

sputum,  and  on  the  mucous  membrane  of  the 
mouth  and  throat.  It  is  markedly  pathogenic 
for  laboratory  animals,  producing  death  of  the 
animal  in  from  24  hours  to  a  week. 

DiPLOcoccus  Pneumonia. 

This  organism  is  oval  in  shape  and  is  found 
in  pairs.    It  is  frequently  found  in  chains. 

Morphology. — The  morphology  is  variable. 
When  it  is  grown  in  bouillon  there  is  a  disposi- 
tion of  the  organism  to  grow  in  pairs.  At  times 
they  grow  in  chains  and  in  the  smear  are  dif- 
ficult to  differentiate  from  the  streptococci. 
The"  capsules  of  the  organism  are  more  ap- 
parent when  the  organism  is  grown  in  broth 
than  when  grown  on  solid  media.  It  varies  in 
length  from  1.5  to  2  microns  in  length,  is  non- 
motile,  has  no  flagella,  forms  no  spores,  and 
cannot  long  resist  unfavorable  conditions. 

Staining. — Stains  readily  with  any  of  the  an- 
alin  stains,  and  by  Gram's  method.  The  cap- 
sule of  this  organism  is  readily  demonstrated 
if  one  mixes  india  ink  with  the  smear  while 
moist. 

Isolation. — The  technique  for  isolation  (em- 
ployed Kiasto)  is  as  follows: 

A  fresh  specimen  of  sputum  is  secured  and  is 


92  PYOERHEA  ALVBOLAKIS 

washed  in  several  changes  of  distilled  water. 
The  object  of  this  step  is  to  free  the  sputum  as 
much  as  possible  of  the  many  varieties  of  or- 
ganisms found  in  the  mouth.  This  step  having 
been  completed,  a  minute  portion  of  the  spec- 
imen thus  treated  is  transferred  to  a  Petri  dish 
in  which  blood  serum  agar  has  been  placed. 
After  24  hours  the  colonies  of  this  organism  be- 
gin to  appear  on  the  culture  media  as  small 
round,  transparent,  dew  drop  points,  which  are 
white  in  color.  The  colony  has  a  dark  center 
surrounded  by  a  pale  margin. 

Growth  on  Agar.— -Grows  poorly  on  agar. 

Growth  ■  on  Blood  Serum  Agar. — On  this 
media  the  best  growth  is  obtained.  The  growth 
along  the  line  of  inoculation  consists  of  small 
transparent  colorless  colonies. 

Groivth  on  One  Per  Cent  Glycerin  Agar. — On 
this  media  this  organism  grows  excellently. 
The  growth  observed  is  the  same  as  noted  on 
the  blood  serum  agar. 

Growth  on  Potato. — Does  not  grow  on  potato. 

Growth  in  Bouillon. — Grows  readily  in  this 
culture  media,  producing  cloudiness. 

Growth  on  Alkaline  Litmus  Milk. — Grows 
readily  in  this  media  and  as  the  growth  prog- 
resses the  media  is  acidiiSied. 


BACTERIOLOGY  93 

Pathogenesis. — Is  deadly  to  laboratory  ani- 
mals and  to  man,  and  is  present  in  the  mouth  of 
man  practically  at  all  times.  The  virulence  of 
this  organism  is  greatly  increased  by  passing  it 
rapidly  through  animals. 

Toxic  Products. — The  toxic  products  are  not 
well  understood.  They  are  supposed  to  be  in- 
tracellular. 

Leptothrix  Buccalis. 

This  organism  is  non-motile,  non-flagellate, 
does  not  form  spores,  and  is  not  culturable. 

Morphology. — Measures  0.5  microns  in  diam- 
eter and  from  10  to  50  microns  in  length. 

Staining. — Stains  readily  with  any  of  the  an- 
ilin  stains  and  by  Gram's  method. 

Culture  Media. — The  author  has  conducted 
many  experiments  endeavoring  to  grow  this 
very  common  organism  of  the  mouth,  but  up  to 
the  present  has  not  succeeded. 

SpIEOCH^TA  ErEFRINGENS. 

This  organism  is  motile,  does  not  form  spores, 
and  is  not  culturable  at  this  time. 

Morphology.  —  The  spirochseta  refringens 
measures  0.5  microns  in  diameter  and  varies  in 
length  from  30  to  40  microns. 

Staining. — Stains  readily  with  any  of  the  an- 
ilin  stains  and  by  Gram's  method. 


CHAPTER  VI. 
Pathology. 

The  sections  described  in  this  chapter  were 
cut  from  a  specimen  taken  from  the  mouth  of 
a  man  about  40  years  old.  The  cause  of  death 
was  endocarditis.  An  examination  of  the  mouth 
a  few  hours  after  death  showed  an  extensive 
pyorrhea.  The  lower  incisors  were  very  loose 
and  on  exploration,  showed  very  deep  pockets. 
Slight  pressure  over  the  pockets  caused  pus  to 
appear  at  the  gingival  margin.  A  further  ex- 
amination showed  the  same  process  present 
around  the  lower  and  upper  molars.  The  spec- 
imen from  which  the  sections  were  cut  was 
taken  from  a  block  of  the  tissue  around  the  up- 
per right  first  molar. 

PEEPAEATIOlSr    OF    THE    SPECIMEN    FOR    StUDY. 

The  specimen  is  removed  en  mass  with  a  fine 
saw  and  fixed  in  Zenker's  solution  for  48  hours. 
Formula  for  Zenker's  solution: 

Potassium  bicarbonate  2.5  gms. 

Sodium  sulphate  1.0  gm. 

Corrosive  sublimate  5.0  gms. 

Glacial  acetic  acid  5.0  c.c. 

Distilled  water  100     c.c. 

94 


PATHOLOGY  95 

It  is  then  removed  from  tlie  solution  and 
washed  in  running  water  for  12  hours.  After 
the  specimen  is  fixed,  small  blocks  are  cut  from 
it  measuring  about  2  mm.  in  thickness,  which 
are  placed  in  the  decalcifying  solution  until  the 
specimen  becomes  thoroughly  decalcified. 

Formula  for  the  decalcifying  solution: 

Nitric  acid 10.     c.c. 

Phloroglucin   0.5  gms. 

Distilled  water  100      c.c. 

The  step  of  decalcification  having  been  com- 
pleted the  specimen  is  transferred  to  a  75  per 
cent  solution  of  alcohol  for  24  hours ;  from  the 
75  per  cent  solution  it  is  transferred  to  an  85 
per  cent  solution  of  alcohol  for  24  hours,  and 
from  the  85  per  cent  solution  to  a  95  per  cent 
solution  of  alcohol  for  24  hours. 

Having  passed  the  specimen  through  the  al- 
cohol it  is  transferred  to  ether  and  alcohol  for 
24  hours  and  then  to  thin  celloidin  for  24  hours. 
From  the  thin  to  medium  celloidin  for  24  hours, 
and  from  the  medium  to  thick  celloidin  for  24 
hours.  After  passing  through  the  thick  cel- 
loidin the  specimen  is  mounted  on  a  tile  block 
and  placed  in  chloroform  for  24  to  48  hours, 
after  which  it  is  ready  to  be  cut  with  the  mi- 
crotome. 


96  PYORRHEA  ALVEOLARIS 

Formula  for  Delafield's  Hematoxylin: 

Solution  No.  I. 

Hematoxylin  Crystals   1     gm. 

Saturated  solution  ammonia  alum..  .400     c.c. 
Alcohol  (95  per  cent)    25     c.c. 

First  dissolve  the  hematoxylin  in  the  alcohol ; 
then  add  the  ammonia  alum  solution.  Place  the 
mixture  in  a  bottle,  set  it  aside  for  a  few  days, 
filter  and  add. 

Solution  No.  II. 

Glycerin  100     c.c. 

Alcohol  (95  per  cent)   100     c.c. 

Stopper  the  bottle  with  a  cotton  plug  and  al- 
low the  solution  to  stand  in  the  light  until  it 
becomes  dark.  Then  filter  and  stopper  with  a 
tight-fitting  cork.  The  section  cut  with  the 
microtome  is  placed  in  10  c.c.  of  this  stain  from 
12  to  24  hours,  after  which  it  is  placed  in  tap 
water  to  which  has  been  added  one  drop  of 
aque  ammoniae,  in  which  it  is  allowed  to  remain 
until  very  black.  It  is  then  transferred  to  a 
solution  of  iron  ammonium  persulphate  until  it 
becomes  a  deep  brown. 

Iron  ammonia  persulphate 2     gms. 

Distilled  water 100     c.c. 


Pathology 


97 


Fig.  VII. — Medium  Laboratory  Microtome.  This  instrument 
will  be  found  very  satisfactory  for  general  use  in  a  laboratory, 
being  of  a  suitable  size,  scope  and  stability  to  perform  all  ordi- 
nary work  accurately.  The  feeding  mechanism,  while  operated 
by  hand,  provides  for  convenient  manipulation  and  affords  a 
wide  range  of  cutting  thickness.  It  is  fitted  with  patented  split 
nut,  having  convenient  handles  by  means  of  which  the  carriage 
may  be  brought  to  the  starting  or  intermediate  positions  instan- 
taneously.   (Courtesy  Bausch  d  Lomb  Opt.  Co.) 


98  PYORRHEA  ALVEOLARIS 

The  section  is  next  transferred  to  distilled 
water  for  5  minutes ;  from  the  distilled  water 
to  85  per  cent  alcohol  for  5  minutes;  from  the 
85  per  cent  alcohol  to  95  per  cent  alcohol  for  5 
minutes;  and  from  the  95  per  cent  alcohol  to 
creasote  until  it  is  transparent. 

After  the  section  is  cleared,  it  is  removed 
from  the  creasote  with  the  section  lifter  and 
placed  upon  a  clean  slide.  Then  place  a  drop  of 
balsam  on  the  section  and  cover  it  with  a 
coverslip,  gently  pressing  the  coverslip  until  it 
is  in  firm  contact  with  the  section  and  the  slide. 

If  a  contrast  stain  is  desired  for  study,  excel- 
lent results  are  obtained  with  Delafield's  hem- 
atoxylin and  a  1  per  cent  solution  of  yellow 
aqueous  eosin.  The  section  is  mounted  on  the 
slide  with  very  thin  celloidin,  and  after  fixation 
to  the  slide  with  celloidin  is  stained  with  hem- 
atoxylin for  10  to  20  minutes.  It  is  next  im- 
mersed in  warm  tap  water  for  1  minute  and 
then  stained  with  the  eosin  solution  for  2  to  4 
minutes.  The  eosin  is  poured  off  and  a  95  per 
cent  alcohol  is  added  to  remove  any  excess  of 
this  stain.  The  section  is  covered  with  crea- 
sote and  set  aside  until  it  is  clear.  The  excess 
of  creasote  is  poured  off  and  the  section  is 
blotted  with  a  clean  blotter.    A  drop  of  balsam 


PATHOLOGY  99 

is  placed  on  the  section,  after  which  it  is  cov- 
ered with  a  coverslip. 

The  photographs  shown  were  stained  with 
the  hematoxylin  and  iron  ammonium  persul- 
phate. 


100  Pyorrhea  aLveoLahis 

Longitudinal  and  Cross-Section  of  the 
Specimen. 

Figure  VIII  shows  a  longitudinal  section  of 
the  specimen  and  presents  for  study  a  section  of 
the  palatine  root  and  the  anterior  buccal  root. 

The  gingival  margin  A  shows  distinctly  a 
separation  of  the  gum  from  around  the  neck  of 
the  tooth.  Passing  down  the  palatine  root  to- 
ward the  apex,  an  expanded  area  in  the  al- 
veolus is  observed  at  B.  This  is  the  beginning 
of  a  pocket  around  the  root  of  the  tooth.  At 
C  a  smaller  area  of  expansion  is  observed  than 
at  B.  The  margin  between  these  points  is  irreg- 
ular in  outline,  and  the  distance  between  the 
root  of  the  tooth  and  the  alveolus  is  variable, 
D  is  the  gum  tissue  around  the  alveolus.  E  is 
the  alveolus  at  the  bifurcation  of  the  roots.  In 
the  substance  of  the  alveolus  are  many  dark 
areas,  which  are  portions  of  the  alveolus  de- 
stroyed by  the  disease. 

The  cross  section  (Figure  IX)  from  which 
slides  were  made  presents  at  A  the  alveolar 
process.  B  is  the  gum  tissue,  G  the  root  of  the 
tooth,  and  D  the  pocket  described  in  Figure 
VIII. 


PATHOLOGY 


101 


Fig.   VIII. — Longitudinal  section  of  the  palatine  root. 


Fig.   IX. — Cross-section  of   the  palatine   root. 


102  PYORRHEA  ALVEOLARIS 

Cross-Section  of  the  Palatine  Root  and  the 
Alveolus. 

An  examination  around  the  palatine  root 
presents  a  very  interesting  picture.  R  is  the 
palatine  root.  Commence  with  RC,  the  root 
canal,  and  pass  to  the  right  to  D,  the  cementum 
of  the  root,  which  is  approximately  normal. 
The  peridental  membrane  E  shows  in  its  sub- 
stance light  areas  that  are  foci  of  destruction, 
irregular  in  size  and  shape.  At  C  the  periden- 
tal membrane  is  greatly  thickened  and  has  in- 
vaded an  area  of  destroyed  alveolus  and  made 
itself  fast.  In  the  upper  part  at  this  point  it 
is  lighter  and  is  composed  of  very  fine  capil- 
laries, very  fine  granular  debris,  and  a  small 
amount  of  fibrinous  material.  This  point  in  all 
probability  is  a  regenerating  area  of  periden- 
tal membrane.  B  shows  light  areas  in  the  sub- 
stance of  the  alveolus,  irregular  in  shape  and 
size.  They  have  no  definite  arrangement  as  to 
their  position.  Some  of  them  are  filled  with 
fine  granular  material;  others  are  partially 
filled  and  still  others  contain  nothing.  Note  the 
area  which  lies  between  the  root  of  the  tooth 
and  the  remaining  alveolus,  cementum,  and 
peridental  membrane  for  the  last  described  va- 


PATHOLOGY 


103 


riety.  Many  times  these  pockets  show  active 
processes  of  destruction  throughout  the  alveo- 
lus, and  in  some  instances  regeneration.  A  is 
a  large  cavity  in  the  substance  of  the  alveolus 
containing  granular  debris  and  small  islands  of 
alveolus  not  completely  destroyed. 


Fig.  X. — Cross-section  of  tlie  palatine  root  and  the  alveolus. 


104  PYORRHEA  ALVEOLARIS  ^ 

Cross-Section  of  the  Anterior  and  Posterior 
Buccal  Roots  and  the  Alveolus. 

In  the  peridental  membrane  A  around  the  an- 
terior buccal  root  ABR  light  areas  C-C  can  be 
observed,  irregular  in  shape  and  size,  and  with- 
out any  definite  arrangement.  Their  margins 
are  smooth  and  regular.  B-B^  is  the  alveolar 
process  between  which  is  passing  from  A  to  A" 
an  extended  portion  of  it  in  the  substance  of  the 
alveolus.  This  cavity  occupied  by  A^'  was  in 
health  alveolus.  The  peridental  membrane  is  a 
tissue  which  possesses  regenerating  properties, 
and  in  addition  thereto  is  constantly  seeking 
points  of  attachment.  Hence,  the  possible  ex- 
planation of  the  invasion  of  the  cavity  by  it.  On 
further  examination  it  is  found  j:hat  it  again 
contracts  itself,  passing  in  a  canal  in  the  alveo  - 
lus,  and  ends  at  A''\  In  the  substance  of  the 
alveolus  at  C  is  the  beginning  of  a  process  of 
destruction  of  the  peridental  membrane  around 
the  posterior  buccal  root  PBR.  At  A'  the  peri- 
dental membrane  of  the  posterior  buccal  root 
PBR  shows  no  areas  of  the  disease.  D-D'-D'' 
are  areas  of  destruction  of  the  alveolus.  D 
shows  a  cavity  that  contains  none  of  the  prod- 
ucts of  destruction.    D'  is  a  cavity  filled  with 


PATHOLOGY. 


105 


granular  debris.  D"  shows  an  active  focus  of 
the  disease  and  contains  granular  debris  and 
fibrinous  material.  E  is  the  cementum  of  the 
anterior  and  posterior  buccal  roots.  jP  is  a  cav- 
ity between  the  anterior  and  posterior  buccal 
roots  and  contains  a  small  amount  of  degener 
ated  alveolus  and  granular  material. 


Fig.    XI. — Ci'oss-section   of   the   anterior   and   posterior   buccal 
roots  and  the  alveolus. 


106  PYORRHEA  ALVEOLARIS 

Cross-Section  of  the  Anterior  and  Posterior 
Buccal  Roots  Including  the  Alveolus. 

This  section  is  from  an  area  farther  up  on 
the  roots  than  that  shown  in  Figure  XI. 

The  anterior  buccal  root  ABR  is  separated 
more  from  the  cementum  A  than  is  observed  in 
Fixure  XI,  and  is  shown  in  sharper  contrast.  It 
is  smooth  in  outline  and  has  a  slight  granular 
appearance.  The  peridental  membrane  B 
shows  in  its  substance  many  foci  of  the  disease. 
They  are  irregular  in  shape,  size  and  arrange- 
ment. D  is  a  large  cavity  between  the  anterior 
and  posterior  buccal  roots  {ABR  and  PBR).  E 
is  a  small  cavity  communicating  with  D.  F  is 
normal  peridental  membrane  around  the  poste- 
rior buccal  root  PBR.  (r  is  a  commencing  focus 
of  the  disease  in  the  membrane  around  the  root. 
RC  is  the  root  canal  of  the  anterior  and  the  pos- 
terior buccal  roots. 

This  photograph  shows  that  the  diseased 
areas  of  the  alveolus  are  much  larger  than  ob- 
served in  Figure  XI,  and  they  contain  little  if 
any  of  the  products  of  destruction. 


PATHOLOGY 


107 


Fig.   XII. — Cross-section   of  the   anterior   and  posterior   buccal 
roots,  including  the  alveolus. 


108  PYORRHEA  ALVEOLARIS 


Cross-Section  of  the  Palatine  Root  and  the 
Alveolar  Process. 

A  is  the  cementum  of  the  root  and  shows  no 
evidence  of  the  disease.  E  is  the  remaining  por- 
tion of  the  peridental  membrane  which  con- 
tains in  its  substance  three  well-defined  foci  of 
the  disease.  D  is  an  island  of  alveolus  bounded 
on  one  side  by  the  diseased  peridental  mem- 
brane and  on  the  other  by  a  cavity.  5  is  a  cav- 
ity, which  during  health  was  occupied  by  al- 
veolus and  peridental  membrane.  In  this  cav- 
ity is  a  considerable  amount  of  granular  debris. 
At  D'  is  observed  a  very  large  cavity  in  the  al- 
veolus filled  with  very  fine  granular  debris  and 
a  small  amount  of  fibrinous  material.  B"^  and 
B'"'  show  a  large  cavity.  B'^'  shows  a  large 
number  of  capillaries  and  fibrinous  material. 
B'"'  shows  fine  granular  debris  and  fibrinous 
material.  C-C  is  alveolus  not  affected  by  the 
disease. 


t>ATHOLOQY 


109 


Fig.  XIII. — Cross-section  of  the  palatine  root  and  the  alveolar 
process. 


110  PYORRHEA  ALVEOLARlS 


Cross-Section  of  the  Anterior  Buccal  Root  and 
the  Alveolus. 

In  the  substance  of  the  peridental  membrane 
G  are  many  light  areas,  irregular  in  shape  and 
variable  in  size.  They  are  foci  of  the  disease  in 
various  stages  of  its  development.  B  is  the 
cementum  in  a  healthy  state.  A'  shows  a  large 
cavity  in  the  substance  of  the  alveolus,  contain- 
ing granular  debris  and  partially  destroyed  al- 
veolus. A  is  the  alveolus  which  has  not  been 
affected  by  the  disease.  £'  is  a  cavity  filled  with 
very  fine  granular  debris. 


PATHOLOGY 


111 


Fig.  XIV. — Cross-section  of  the  anterior  buccal  root  and  the 
alveolus. 


112  PYORRHEA  ALVEOLARiS 

Gross-Section  of  the  Palatine  Root  and  the 
Alveolar  Process. 

The  peridental  membrane  A  shows  foci  of 
degeneration  and  marked  thickening.  E  is  the 
cementum  in  a  healthy  state,  C  is  the  periden- 
tal membrane  of  an  approximate  normal  thick- 
ness, and  contains  in  its  substance  very  small 
foci  of  destruction.  B  is  the  alveolus  not  af- 
fected by  the  disease.  B'  is  a  small  island  of  al- 
veolus which  stands  out  in  sharp  contrast  to 
the  surrounding  alveolus  and  is  in  all  likelihood 
a  regenerated  area  of  it.  i)  is  a  canal  around 
which  are  concentric  whorls  of  the  alveolus, 
and  the  author  believes  it  is  a  foramen  through 
which  blood  vessels  passed  during  life.  A-A\ 
the  peridental  membrane,  has  invaded  a  small 
destroyed  cavity  in  the  alveolus.  The  upper 
portion  of  the  peridental  membrane  stands  out 
in  sharp  contrast  and  is  composed  of  very  fine 
fibers  of  peridental  membrane  which  in  all  prob- 
ability are  regenerating  fibers.  B^'  shows  a 
cavity  in  the  substance  of  the  alveolus  filled 
with  fibrinous  material  and  fine  granular  debris. 
Many  other  similar  foci  are  noted.  Some  are 
not  so  well  filled,  while  others  are  completely 
filled. 


PATHOLOGT 


113 


Fig.  XV. — Cross-section  of  the  palatine  root  and  the  alveolar 
process. 


114  PYORRHEA  ALVEOLiARIS 


Cross-Section  of  the  Palatine  Root  Including  a 
Small  Island  of  the  Alveolar  Process. 

A  is  the  palatine  root.  B  is  the  cementum 
and  shows  no  evidence  of  the  disease.  E  is  the 
alveolar  process  which  is  not  affected  by  the  dis- 
ease. C-C  show  fibers  of  the  peridental  mem- 
brane attached  to  the  alveolus.  C'-C"  is  the 
peridental  membrane  extending  out  into  the 
cavity  of  the  alveolus.  D-D'-D''  are  degener- 
ated areas  in  the  substance  of  the  peridental 
membrane.  The  edges  of  the  foci  are  smooth  and 
regular  and  some  of  them  contain  fine  granular 
debris,  while  others  contain  nothing.  Scattered 
throughout  the  substance  of  the  peridental 
membrane  are  numerous  round  cells. 


PATHOLOGY 


115 


Fig.  XVI. — Cross-section  of  the  palatine  root,  including  a  small 
island  of  the  alveolar  process. 


116  PYORRHEA  ALVEOLARIS 


Cross-Section  Near  Anterior  Buccal  Root. 

The  alveolar  process  A-A'-A"-A''^  bounds  a 
cavity  now  occupied  by  peridental  membrane, 
which  during  health  was  occupied  by  alveolus. 
The  peridental  membrane  B-B  shows  in  its  sub- 
stance light  areas  which  are  foci  of  the  disease. 
At  C-C  are  very  large  areas  composed  of  gran- 
ular debris  and  the  uncompleted  destruction  of 
the  peridental  membrane  at  these  points.  D-B' 
show  many  round  cells  scattered  without  ar- 
rangement in  the  substance  of  the  peridental 
membrane. 


PATHOLOGY 


117 


Fig.   XVII. — Cross-section   near  anterior  buccal  root. 


118  PYORRHEA  ALVEOLARIS 


Cross-Section  From  Near  Palatine  Root. 

A-A'  are  islands  of  the  alveolus  not  affected 
by  the  disease.  B-B'-B''  show  a  fatty  degener- 
ation of  the  alveolus.  C-C'-C'-C'  is  the  peri- 
dental membrane.  B  shows  round  cells  in  the 
matrix  of  the  fatty  degenerated  area.  Eound 
cells  are  also  observed  in  the  peridental  mem- 
brane and  lying  loose  in  the  degenerated  area. 


PATHOLOGY 


119 


Fig.   XVIII. — Cross-section   from   near  palatine   root. 


120  PYORRHEA  ALVEOLARIS 


Cross-Section  of  the  Anterior  and  Posterior 
Buccal  Roots  Including  the  Peri- 
dental Membrane. 

ABR  is  the  anterior  buccal  root.  B  is  the 
diseased  peridental  membrane  around  this  root. 
In  its  substance  are  many  light  areas  variable 
in  size  and  shape,  with  smooth  and  regular  mar- 
gins. C  is  the  cementum  and  is  not  affected  by 
the  disease.  A'  is  an  area  in  the  peridental 
membrane  that  has  not  been  affected  by  the 
disease.  A  is  the  peridental  membrane  of  the 
posterior  buccal  root  and  is  not  affected  by  the 
disease.  C"  is  the  cementum  of  this  root  and 
shows  no  evidence  of  the  disease. 


PATHOLOGY 


121 


Fig.  XIX. — Cross-section  of  the  anterior  and  posterior  buccal 
roots,  including  the  peridental  membrane. 


122  PYORRHEA  ALVEOLABIS 


A  Field  Magnified  One  Thousand  Times. 

In  this  field  one  observes  many  round  cells 
and  two  very  large  cells.  These  large  cells  are 
quite  constant  i*i  the  specimen  the  author  used, 
but  were  not  regularly  distributed  throughout 
it.  The  large  cells  are  variable  in  size  and 
shape.  Observe  that  round  cells  are  present  in 
the  cell  substance  of  the  large  cells.  These  cells 
are  not  giant  cells,  nor  are  they  lymphocytes. 
Their  significance  and  relation  to  pyorrhea  is 
still  being  studied  by  the  author,  and  it  is  hoped 
the  problem  of  the  presence  of  these  cells  in  al- 
veolus affected  by  pyorrhea  will  be  solved  some 
time  in  the  near  future.  B-B^-B'^  show  fibers  of 
the  peridental  membrane.  G-C'-G'^-G'"  are 
round  cells. 


PATHOLOGY 


123 


Fig.  XX. — A  field  magnified  one  thousand  times. 


CHAPTER  Vn. 
Technique  for  Making  Vaccines. 

The  technique  for  making  vaccines  is  a  very 
simple  process  and  offers  very  little  difficulty 
to  the  beginner. 

The  first  essential  step  is  the  culture  media 
which  has  been  described.  The  second  is  the 
preliminary  technique  for  the  mouth  and  teeth, 
as  follows:  The  patient  is  instructed  not  to 
brush  the  teeth  or  use  a  mouth  wash  for  three 
days  before  returning  to  the  office  after  the 
first  visit.  At  the  end  of  this  time  the  patient 
returns  and  plants  are  made  from  the  disG«ised 
gums.  After  the  plant  has  been  obtained,  a 
smear  is  made  from  the  gums  of  all  teeth  af- 
fected by  the  disease.  This  having  been  done 
the  gums  and  teeth  are  carefully  examined  and 
the  history  taken  to  determine  which  variety  of 
the  disease  is  present.  The  gums  affected  are 
wiped  with  a  piece  of  sterile  cotton  dipped  in 
a  50  per  cent  solution  of  alcohol.  The  area  thus 
treated  is  protected  from  the  lips  or  cheeks  by 
a  piece  of  sterile  cotton.    The  platinum  loop  is 

124 


TECHNIQUE  FOR  MAKING  VACCINES  125 

sterilized  and  placed  wliere  it  will  not  become 
contaminated.  The  pledget  of  cotton  is  then 
removed  from  over  the  area  treated,  the  fingers 
holding  the  lips  or  cheeks  away  from  the  gum 
from  which  the  specimen  is  to  be  taken.  The 
gum  is  massaged  toward  the  gingival  margin 
with  the  index  finger  of  the  right  hand  until 
the  exudate  appears.  The  handle  of  the  plati- 
num loop  is  held  with  the  thumb  and  fingers  of 
the  right  hand,  and  the  loop  brought  in  contact 
with  the  exudate.     A  small  portion    of    it    is 


Fig.  XXI. — Platinum  loop. 

placed  on  the  slide,  and  the  remaining  portion 
is  used  to  inoculate  the  culture  media.  The  slide 
made  is  labeled  with  the  name  of  the  tooth  from 
which  the  smear  was  obtained,  and  is  set  aside. 
Each  tooth  affected  by  the  malady  is  treated  in 
this  manner. 

One  tube  of  agar  or  broth  may  be  used  for  all 
of  the  teeth  involved.  The  better  plan,  how- 
ever, is  to  inoculate  one  with  the  products  from 
the  upper  and  another  from  the  lower  teeth. 
After  the  tubes  have  been  inoculated  they  are 


126  PYORRHEA  ALVEOLARIS 

labeled  with  the  patient's  name  and  date  and 
then  placed  in  the  incubator  for  24  hours.  If 
the  case  in  hand  is  a  bad  one,  it  is  best  to  inoc- 
ulate a  second  set  of  tubes  from  the  first  set, 
because  in  all  likelihood  the  additional  quantity 
will  be  needed. 

If  agar  is  used  for  growing  the  culture  it  is 
treated  as  follows :  Place  in  the  tube  from  5 
to  10  c.c.  of  an  0.85  per  cent  solution  of  salt. 
Then  take  a  small  glass  rod  and  carefully  re- 
move the  growth  from  the  surface  of  the  agar. 
Place  this  emulsion  in  a  clean  test  tube  and 
seal  the  tube  in  a  gas  flame.  The  tube  is  thor- 
oughly shaken  for  15  to  20  minutes,  the  object 
of  which  is  to  thoroughly  emulsify  the  bacteria. 
After  shaking,  it  is  best  to  filter  the  emulsion 
through  cotton  to  rid  it  of  any  clumps  of  bac- 
teria that  are  present,  and  thus  render  the 
standardization  of  the  emulsion  to  less  error 
as  to  the  number  of  bacteria  contained  in  a 
known  quantity. 

If  broth  is  used  a  better  medium  of  growth 
will  be  had  for  many  bacteria.  It  comes  nearer 
to  the  conditions  of  the  mouth  in  which  the 
organisms  grow,  and  is  probably  the  better 
method  of  the  two.  The  author  employs  the 
following  technique  when  broth  is  used:    The 


TECHNIQUE  FOR  MAKING  VACCINES 


127 


tubes  having  been  incubated  for  18  hours 
are  removed  from  the  incubator.  They  are  then 
mixed  and  one-half  of  the  broth  is  passed 
through  a  porcelain  filter.  The  filtrate  thus  ob- 
tained is  used  as  the  diluting  fluid.  In  addition 
to  this,  the  filtrate  contains  the  by-products  of 
the  bacteria.  The  author  believes  that  the  by- 
products are  a  necessary  part  of  the  vaccine. 


Containers  for  Vaccines. 

The  selection  of  containers  for  the  vaccine  is 
left  to  the  reader.    The  author  finds  the  small 


^<^y  15  1913 
^<^P.  2,0  c<^ 


Fig.  XXII. — ^Vaccine  con- 
tainer, with  rubber  cap. 


Miss  Brown- 


Fig.  XXIII.  —  Individual 
vaccine  container,  sealed  in 
gas  flame. 


128  PYORRHEA  ALVEOLARIS 

wide-mouthed  bottle  an  excellent  container ;  and 
the  small  rubber  cap  with  which  some  of  the 
manufacturers  preserve  their  culture  media  is 
an  excellent  means  for  covering  the  mouth  of 
the  bottle. 

The  vaccine,  having  been  made  and  stand- 
ardized, is  placed  in  one  of  these  bottles,  after 
which  the  rubber  cap  is  slipped  over  the  mouth 
of  the  bottle  and  cresol  carefully  rubbed  over 
the  surface  and  at  the  margin  with  which  it 
comes  in  contact  with  the  bottle.  When  the 
cresol  evaporates  it  becomes  very  gummy  and 
thereby  seals  the  bottle.  In  addition  to  this  it 
gums  over  the  hole  made  when  the  rubber  is 
punctured  to  draw  the  vaccine  into  the  hypo- 
dermic. Each  dose  of  the  vaccine  can  also  be 
put  into  a  separate  tube  and  the  ends  sealed  in 
a  gas  flame.  ^^Hien  the  patient  is  ready  to  be 
vaccinated  the  end  of  the  container  is  broken 
off  and  its  contents  drawn  into  the  hypodermic. 

Technique  for  the  Sterilization  of  Vaccines. 

Either  of  the  two  following  methods  can  be 
used  for  the  sterilization  of  the  vaccines : 

I.  The  emulsion  having  been  prepared  as 
previously  described,  enough  cresol  is  added  to 
make  a  1  per  cent  solution.    This  having  been 


TECHNIQUE  FOR  MAKING  VACCINES  129 

done,  the  bacterial  emulsion  is  transferred  to 
the  container  which  may  be  a  bottle  or  small 
ampulla.  If  a  bottle  is  used  the  mouth  is  sealed 
with  a  rubber  cap  and  placed  in  a  water  bath  at 
a  temperature  of  56°  C.  The  vaccine  is 
allowed  to  remain  in  the  water  bath  for  30 
minutes  for  3  consecutive  days.  The  bottle  is 
then  labeled  with  the  patient's  name  and  is 
ready  for  use. 

II.  If  the  above  technique  is  not  desired, 
enough  carbolic  acid  can  be  added  to  the  emul- 
sion of  bacteria  to  make  a  1  per  cent  solution. 
It  is  then  thoroughly  shaken.  The  object  of  the 
shaking  is  to  make  as  perfect  a  solution  as  pos- 
sible. The  solution  is  then  transferred  to  a, 
bottle  and  the  rubber  cap  placed  over  the 
mouth  and  sealed;  or  each  ampulla  can  be 
charged  with  the  vaccine  and  sealed  in  a  gas 
flame.  The  container  is  labeled  with  the  pa- 
tient's name,  put  in  a  safe  place  for  48  hours, 
and  is  then  ready  for  use. 


CHAPTER  VIII. 

Technique  for  Collecting  Blood  Corpuscles. 

In  a  small  test  tube  place  2  c.c.  of  a  2  per 
cent  solution  of  sodium  citrate: 

Sodium  citrate 2     gms. 

Distilled  water  100     c.c. 

The  most  convenient  point  from  which  blood 
can  be  readily  obtained  is  at  the  root  of  the 
nail  of  the  thumb  or  fingers. 

Having  selected  the  point  from  which  the 
blood  is  to  be  taken,  the  following  steps  are 
necessary :  The  part  selected  is  washed  vigor- 
ously with  soap  and  water,  after  which  it  is 
rinsed  mth  sterile  warm  water  followed  by 
rinsing  in  50  per  cent  solution  of  alcohol.  Place 
a  bandage  or  a  piece  of  rubber  tubing  around 
the  phalanx  below  the  one  from  which  the  blood 
is  to  be  drawn.  In  the  opposite  hand  hold  a 
fine  bistoury  or  hagadorn  needle.  The  distal 
phalanx  from  which  the  blood  is  to  be  drawn  is 
flexed  and  the  puncture  made.  The  first  drop 
of  blood  is  allowed  to  escape,  but  the  remaining 

130 


TECHNIQUE  FOR  COLLECTING  BLOOD  CORPUSCLES  131 


Fig-.    XXIV. — Showing'  position   of   tube     for    collecting-    blood 
corpuscles. 


Fig:.  XXV. — Water  motor  centrifuge  which  is  well  suited  for 
collecting  precipitate  of  blood  corpuscles.  (Courtesy  Ernst  Leitz, 
New  York.) 


132  PYORRHEA  ALVEOLARIS 

drops  are  collected  in  the  test  tube  containing 
the  citrate  solution  by  holding  the  tube  in  such 
a  position  as  will  allow  the  blood  to  flow  into  it. 
(See  Figure  XXIV.)  The  blood  having  been  col- 
lected is  centrifuged  for  15  minutes.  The 
supernatent  fluid  is  pipetted  off  and  the  blood 
corpuscles  thus  obtained  are  used  to  standard- 
ize the  vaccine. 

Standardization  of  Vaccines. 

A  vaccine  is  standardized  by  one  of  two 
methods.  The  first  method  is  as  follows :  An 
equal  quantity  of  an  emulsion  of  bacteria  and 
blood  cells  is  drawn  into  a  capillary  pipette, 
after  which  they  are  thoroughly  mixed  by  draw- 
ing the  mixture  back  and  forth  from  the  sur- 
face of  a  slide.  This  step  having  been  com- 
pleted a  smear  of  the  mixture  is  prepared  in 
the  same  manner  as  described  in  the  technique 
for  making  a  blood  smear  (page  61).  A  card 
is  then  ruled  for  blood  cells  to  be  counted.  The 
count  is  commenced  of  the  number  of  bacteria, 
and  the  blood  cells  in  one  field  are  counted. 
This  step  is  repeated  until  the  20  squares  have 
been  counted.  After  the  step  of  counting  is 
completed,  the  content  is  found  by  the  follow- 
ing proportion:     The  number  of  blood  cells 


TECHNIQUE  FOR  COLLECTING  BLOOD  CORPUSCLES  133 


Fig.    XXVI. — Position    for    making   emulsion    of   bacteria   and 
blood  corpuscles. 


Fig.    XXVII. — Position    for   making   the    mixture    of    bacteria 
and  blood  cells. 


134 


PYORRHEA  ALVEOLARIS 


counted  is  to  the  number  of  bacteria  counted, 
as  five  million  (x  10)  is  to  X  equals  the  number 

Chart  showing  method  of  counting  and 
proportion  of  standardizing  vaccine. 


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000 

(xlOX)  =:Ans 

of  bacteria  contained  in  1  c.c.  of  the  emulsion. 
Thus,  for  example,  suppose  the  following  to  bo 


Fig.   XXVIII. — Pipette   used   for   mixing   blood   corpuscles   and 
emulsion  of  bacteria,  for  standardizing  vaccine. 


TECHNIQUE  FOR  COLLECTING  BLOOD  CORPUSCLES  135 

correct :  The  number  of  blood  cells  counted 
in  20  squares  is  94  and  the  number  of  bacteria 
88.    The  problem  would  be  represented  thus: 

94:  88::  5,000,000  (xlO)  :  X  =  the   number   of 
bacteria  contained  in  1  c.c.  of  the  emulsion. 

With  the  same  precision  the  counting  cham- 
ber of  the  hemocytometer  can  be  used,  and  the 


11=            :                     ;;:    ;; 

Fig.    XXIX. — Turck's    ruled    hemocytometer. 

white  blood  corpuscle  counting  pipette  for  mak- 
ing the  dilution  of  the  emulsion.  To  dilute  the 
emulsion,  a  solution  of  methylene  blue  (which 
stains  the  bacteria  blue)  is  used  as  the  dilut- 
ing fluid,  the  dilution  made  is  one  in  twenty. 
The  Tiirck  ruling  is  an  excellent  one  for  this 
purpose.  The  number  of  bacteria  contained  iu 
the  large  center  squares  are  counted  and  then 
the  contents  of  1  c.c.  is  found  by  the  following- 
equation:     The   number    of   bacteria    counted 


136  PYORRHEA  ALVEOLARIS 

times  the  dilution ;  times  four  thousand  squares ; 
over  the  number  of  squares  counted ;  equals  the 
contents  of  1  cm.  Which,  if  multiplied  by  ten, 
equals  the  contents  of  1  c.c.  For  example,  sup- 
pose the  number  of  bacteria  counted  is  250,  and 
the  dilution  is  one  in  twenty,  and  the  number  of 


Fig.  XXX. — A  field  as  observed  when  counting-  bacteria  and 
blood  cells  when  a  vaccine  is  being  standardized. 

squares  counted  400.     The  problem  would  be 
represented  thus : 

250x20x4,000  ^       ,     .    .    . 

=the  number  of  bacteria  to  1  cm. 

400  Sq.  counted 

which,  when  multiplied  by  ten,  equals  the  num- 
ber in  1  c.c. 

After  the  determination  of  the  bacterial 
count  of  the  vaccine,  the  dose  can  be  regulated 
very  accurately  with  a  graduatel  hypodermic. 


CHAPTER  IX.  ■ 

Technique  for  Vaccination. 

The  point  selected  for  vaccination  can  be  any 
part  of  the  body,  the  arm  being  the  most  con- 
venient. The  point  selected  for  this  purpose 
should  be  made  as  aseptic  as  possible.  The 
tincture  of  iodin  is  an  excellent  agent  for  this 
purpose,  though  it  may  be  said  that  experiment 
has  demonstrated  that  the  tincture  of  iodin 
does  render  the  skin  germ-free.  As  there  is  no 
better  agent  than  the  tincture  of  iodin  for  this 
purpose,  its  use  must  be  contented  with.  If  al- 
cohol is  used  instead  of  tincture  of  iodin, 
the  solutions  which  are  antiseptic  range  be- 
tween 50  and  85  per  cent. 

Reaction  op  the  Vaccine. 

The  reaction  of  the  vaccine  is  very  impor- 
tant, as  the  increase  or  decrease  of  the  dose  de- 
pends upon  it.  The  reaction  as  a  rule  begins 
from  5  to  10  hours  after  the  vaccination  and  is 
first  characterized  by  a  rheumatic  feeling  of 
the  part,  which  soon  after  is  followed  by  ten- 

137 


138  PYOKRHEA  ALVEOLARIS 

derness.  Inflammation  then  manifests  itself. 
The  arm  in  some  instances  becomes  very  pain- 
ful on  movement,  and  palpation  at  the  point  of 
vaccination  is  very  painful.  The  arm  in  some 
cases  is  swollen  for  a  considerable  distance 
around  the  point  of  vaccination,  causing  the  pa- 
tient alarm.  Thinking  that  blood  poisoning  has 
occurred,  he  calls  at  the  office.  This  condition 
may  cause  great  alarm  the  first  time  it  is  ob- 
served, but  if  the  vaccine  has  been  correctly 


Fig.   XXXI. — Position   of   arm   for   vaccination. 

sterilized,  either  by  fractional  sterilization  or 
carbolic  acid,  rest  assured  that  the  reaction  thus 
observed  is  indicative  of  an  active  process  in 
which  the  antibodies  are  being  manufactured  in 
the  tissues  that  have  the  ability  to  raise  the  im- 


TECHNIQUE  FOR  VACCINATION  139 

munity  of  the  patient.  The  height  of  the  re- 
action is  generally  reached  after  the  first  24 
hours.  After  this  time  the  tenderness  at  the 
point  of  vaccination  and  the  surrounding  tissues 
becomes  less  and  less,  and  after  the  fourth  day 
has  disappeared,  and  the  patient  given  a  second 
vaccination  in  the  other  arm. 

Caution! — At  no  time  during  the  treatment 
vaccinate  a  patient  in  the  place'  previously 
treated,  because  if  this  is  done  the  reaction  is 
very  slight  and  the  patient  not  benefited 
thereby.  Hence,  remember  that  at  each  vacci- 
nation a  new  point  is  selected,,  using  alternate 
arms  for  the  vaccination,  and  at  a  distant  point 
from  that  selected  at  a  previous  time. 

The  index  of  the  dose  is  best  determined  by 
the  extent  of  the  local  reaction  around  the  point 
of  vaccination  and  the  soreness  of  the  gums 
after  the  vaccination.  The  soreness  of  the  part 
locally,  indicates  a  great  deal  to  the  observer, 
for  it  is  soon  learned  that  the  ratio  of  the  dose 
to  the  reaction  is  a  good  one.  With  the  local 
reaction — its  tenderness  and  inflammation,  one 
frequently  finds  a  similar  process  of  the  gums 
and  the  teeth.  If  the  tenderness  of  the  gums  is 
very  great  and  there  is  an  increase  of  pus 
around  the  teeth  involved,  the  patient    is    in 


140  PYOERHEA  ALVEOLARIS 

what  is  called  a  negative  stage,  and  should  not 
be  vaccinated  for  a  week.  At  the  end  of  this 
time  another  dose  is  given  smaller  than  the  first. 
The  first  dose  which  the  author  gives  is  never 
under  five  hundred  million  and  in  some  in- 
stances eight  to  nine  hundred  million  organ- 
isms per  c.c.  This  dosage  is  very  heroic  and 
many  times  .produces  a  violent  reaction.  In 
some  instances  the  patient  has  a  chill  and  fever. 
The  object  of  this  large  dose  is  to  place  the  pa- 
tient in  a  negative  stage  in  order  that  it  may 
be  determined  if  any  other  teeth  than  those 
from  which  the  culture  was  obtained  are  af- 
fected by  the  disease.  A  smaller  dose  is  given 
after  the  first  and  the  reaction  is  carefully  noted 
at  the  point  of  vaccination,  as  well  as  the  con- 
dition of  the  gums  and  state  of  the  teeth. 


CHAPTER  X. 

Technique  for  Making  Capillary  Pipettes. 

The  glass  selected  for  making  fine  capillary 
pipettes  should  be  soft  and  the  lumen  measure 
from  2  to  3  mm.  The  glass  can  be  cut  to  any 
length  desired,  but  the  author  generally  uses  a 
piece  from  4  to  6  inches  in  length.  The  glass 
tubing  is  held  in  the  gas  flame  until  it  becomes 
very  soft,  and  as  soon  as  this  stage  is  reached 
the  softened  portion  is  grasped  by  a  pair  of 
thumb  forceps  held  in  the  right  hand.  In  the 
process  of  drawing  the  pipette  the  right  hand 
is  slowly  moved  away  from  the  body  of  the 
glass  tubing,  while  the  left  hand  remains  sta- 
tionary. This  outward  movement  of  the  hand 
is  continued  until  the  desired  calibre  is  ob- 
tained. The  thin  capillary  portion  is  then 
broken  off  to  the  desired  length  and  bent  to  any 
angle  desired.  The  pipette  is  held  in  the  left 
hand  until  cool.  A  small  piece  of  cotton  is 
loosely  packed  in  the  opposite  end  to  the  capil- 
lary portion,  after  which  a  piece  of  rubber  hose 
is  slipped  over  this  end.  The  pipette  is  then 
ready  for  use. 

141 


142  PYORRHEA  ALVEOLARIS 


Technique  for  the  Application  of  Drugs  With 
Pipettes. 

The  rubber  hose  attached  to  the  pipette  is 
held  between  the  lips  and  the  pipette  is  firmly 
held  by  the  thumb,  index  and  second  fingers  of 
the  right  hand.  The  point  of  the  pipette  is  im- 
mersed in  the  drug  to  be  applied  and  by  gen- 
tle suction  any  desired  amount  is  drawn  into 


■^v^ 


P/l-e-tte. 


S) 


Fig-.   XXXII. — Pipette  and  attached  rubber  hose. 

the  pipette.  The  pipette  is  then  gradually 
passed  between  the  root  of  the  tooth,  the  gum 
and  the  alveolus  to  the  bottom  of  the  pocket. 
The  contents  of  the  pipette  is  then  discharged. 
The  pipette  is  withdrawn  and  a  piece  of  sterile 
cotton  placed  over  the  gum. 


CHAPTER  XI. 
Local  and  Prophylactic  Treatment. 

Instbumentation. 

Careful  instrumentation  is  a  very  important 
part  of  the  treatment  and  should  be  done  with 
precision.  The  instrument  should  be  firmly  held 
and  not  allowed  to  slip,  as  considerable  injury 
may  be  done  to  the  gum  and  peridental  mem- 
brane if  it  slips  and  slides  about  in  the  process 
of  scaling  the  teeth.  The  instrument  should 
therefore  be  carefully  and  definitely  placed  on 
the  root  of  the  tooth  above  the  deposit  of  tartar, 
and  gradual  and  firm  force  exerted,  while  at 
the  same  time  the  deposit  is  drawn  from  the 
pocket.  Repeat  this  step  until  the  deposit  of 
tartar  is  removed  from  the  root  of  the  tooth. 

Do  Not  Hurby.  Even  if  only  one  root  is 
cleaned  at  a  sitting  and  the  time  required  to  do 
it  is  one  hour,  be  sure  that  the  root  is  free  from 
all  tartar  before  ceasing  your  work. 

The  process  of  scaling  is  made   very  much 

143 


144  PYORRHEA  ALVEOLARIS 

easier  if  the  following  is  applied  with  a  capil- 
lary pipette : 

Phloroglucin 1     gm. 

Sulphuric  acid  15     c.c. 

Distilled  water  100     c.c. 

The  technique  for  the  application  of  the  above 
solution  is  very  simple.  Draw  into  a  capillary 
pipette  the  desired  quantity  of  the  solution. 
Carefully  pass  the  pipette  into  the  deepest  por- 
tion of  the  pocket,  moving  the  pipette  with  great 
care  from  side  to  side,  while  at  the  same  time 
blowing  gently  into  the  rubber  hose,  thus  plac- 
ing the  solution  at  any  desired  point.  As  soon 
as  the  contents  of  the  pipette  has  been  dis- 
patched, withdraw  it  from  the  pocket  and  care- 
fully place  over  the  gum  a  piece  of  cotton.  The 
reaction  which  occurs  is  that  of  sulphuric  acid 
on  the  inorganic  elements  of  which  the  tartar  is 
composed.  The  phloroglucin  prevents  a  de- 
structive action  of  the  acid  on  the  organic  sub- 
stances of  an  area  thus  treated.  The  advantage 
of  the  solution  can  be  readily  seen  by  this  ac- 
tion. The  solution  loosens  the  deposit  and 
makes  its  removal  an  easier  matter  than  when 
an  instrument  is  used  without  it.  The  acid 
solution  is  placed  in  the  pocket  several  times 
while  scaling  the  root.    It  is  impossible  to  say 


LOCAL  AND  PROPHYLACTIC  TREATMENT     145 

how  many  applications  of  this  acid  solution 
should  be  made.  The  operator  must  use  his  own 
judgment  in  its  application.  The  tartar  having 
been  removed  from  the  root  of  the  tooth,  the 
next  step  is  to  rid  the  lining  of  the  pocket  of 
the  epithelium,  because  no  union  can  occur  be- 
tween the  gum  and  the  peridental  membrane  un- 
less a  raw  bleeding  surface  is  present.  This  is 
generally  accomplished  with  an  acid  solution  or 
by  a  normal  solution  of  potassium  hydroxide 
(40  grams  in  1,000  c.c.  of  distilled  water).  The 
author  has  secured  the  best  results  by  the  use 
of  antiformin.  Draw  into  the  pipette  a  very 
small  amount  (not  over  2  drops).  Carefully 
pass  the  pipette  into  the  pocket  and  with  a  side 
to  side  movement  discharge  its  contents  into  the 
deeper  portions  of  the  pocket.  Allow  either  the 
potassium  hydroxide  or  the  antiformin  to  re- 
main in  the  pocket  from  1  to  3  minutes,  after 
which  time  neutralize  with  an  N/10  hydrochloric 
acid  solution.  After  the  hydrochloric  acid  solu- 
tion has  been  placed  in  the  pocket  it  is  swabbed 
out  with  a  pledget  of  cotton  twisted  on  a  broach. 
When  the  treatment  of  the  pocket  with  the  al- 
kalies and  the  acid  is  completed,  a  cataract 
knife  is  passed  into  the  pocket  and  the  adhering 
fibers  of  the  peridental  membrane  which  form 


146  PYORRHEA  ALVEOLARIS 

the  boundaries  of  the  pocket  are  loosened  and 
cut.  The  object  of  this  step  is  to  induce  the  re- 
generation of  the  fibers  and  their  attachment 
to  the  root  and  the  gum  which  overlies  the 
pocket.  This  step  having  been  completed  draw 
a  small  amount  of  balsam  of  peru  containing 
soudan  III  into  the  pipette,  again  pass  the 
pipette  into  the  deepest  portion  of  the  pocket 
and  discharge  its  contents.  The  pipette  is  then 
withdrawn  and  a  pledget  of  cotton  is  placed  on 
the  gum  overlying  the  pocket. 

Balsam,  of  peru    25      c.c. 

Soudan  III  1     gm. 

Caution  !• — Do  not  treat  any  tooth  which  has 
not  a  pocket.  The  treatment  of  teeth  which 
have  no  pockets  is  mercenary  and  not  profes- 
sional ;  however,  do  not  interpret  this  statement 
to  mean  that  tartar  is  not  to  be  removed  if  pres- 
ent at  the  neck  of  a  tooth.  It  should  be  removed 
and  the  point  at  which  it  has  collected  made  as 
smooth  as  possible.  Each  tooth  affected  by 
pyorrhea  should  receive  treatment  as  outlined 
or  given  similar  treatment  with  such  systemic 
treatment  as  indicated  by  the  physician,  as- 
sisted with  the  AUTOGENOUS  VACCINES,  which  in 
practice  have  proven  to  be  a  most  valuable  ad- 
junct in  the  treatment  of  this  disease. 


INDEX 


Agar,  autoclaving  of,  72 

preparation  of,  70 

titration  of,  74 
Arnold  steam  sterilizer,  65 
Autoclav,  71 
Autoclaving  of  agar,  72 

B 

Bacillus  pyocyaneous,  89-91 
growth  on  agar,  90 

in  bouillon,  90 

on  potato,  90 

in  milk,  90 
isolation,  89 
morphology,  89 
pathogenesis,  90 
staining,  89 
Bacteria,  most  commonly  observed  in  pyorrhea: 
bacillus  pyocyaneous,  89 
diplococcus  pneumonia,  91 
leptothrix  buccalis,  93 
spirochseta  refringens,  93 
staphylococcus  pyogenes  albus,  79 

aureus,  83 

citreus,  85 

fetidis,  85 
streptococcus  pyogenes,  87 

147 


148  tNDEX 

Bacteriology,  79-93 

Bacteriological  irritants,  variety  resulting  from,  58-60 

age,  58 

bacteriology,  59 

diagnosis,  59 

diet,  60 

differential  diagnosis,  59 

etiology,  58 

gum,  color  of,  58 

occupation,  58 

pathology,  58 

prognosis,  60 

sex,  58 

social  conditions,  58 

symptomatology,  59 

treatment,  60 
Bismarck-Brown  solution,  technique  for  making,  68 
Blood  corpuscles,  technique  for  collecting,  130 
Blood  smear,  technique  for  making,  61 
point  selected,  61 
position  for  making,  62 
staining  slide,  technique  for,  62 
Broth,  preparation  of,  76 
Burette  bottle  and  wooden  holder,  73 


Capillaky  pipettes,  technique  for  making,  141 
Carbol  gentian,  technique  for  making,  68 
Centrifuge,  water  motor,  131 
Chemical  irritants,  variety  resulting  from,  52-54 

age,  52 

bacteriology,  53 

diet,  54 

diagnosis,  53 

differential  diagnosis,  53 

etiology,  52 


INDEX  ■  149 


Chemical — Cont'd. 

gum,  color  of,  53 

occupation,  52 

pathology,  53 

sex,  52 

social  conditions,  52 

symptomatology,  54 

treatment,  54 
Culture  media,  technique  for  making,  70 

agar,  autoclaving  of,  71 
preparation  of,  70 
titration  of,  74 

broth,  preparation  of,  76 

meat  infusion,  preparation  of,  70 

tubing  and  sterilization  of,  technique  for,  77 


Decalcifying  solution,  formula  for,  95 
Delafield's  hematoxylin,  formula  for,  96 
Diabetic  variety  of  pyorrhea,  18-23 

age,  18 

bacteriology,  20 

diagnosis,  20 

differential  diagnosis,  20 

etiology,  18 

exacerbations,  19 

extraction  of  teeth  in,  20 

gum,  color  of,  18,  20 

hemorrhage,  19 

pathology,  18 

prognosis,  22 

sex,  18 

social  conditions,  18 

symptomatology,  21 

treatment,  23 
diet  in,  23 


150  INDEX 

Differential  blood  count,  63 
Diplococcus  pneumonia,  91-93 
growth  on  agar,  92 

in  alkaline  litmus  milk,  92 

on  blood  serum  agar,  92 

in  bouillon,  92 

on  one  per  cent  glycerin  agar,  92 

on  potato,  92 
isolation,  91 
morphology,  91 
pathogenesis,  93 
staining,  91 
toxic  products,  93 


Gasteo-intestiin'al  toxemic  variety  of  pyorrhea,  36-40 

age,  36 

bacteriology,  37 

diagnosis,  38 

differential  diagnosis,  38 

etiology,  36 

gum,  color  of,  36 

pathology,  36 

prognosis,  40 

sex,  36 

social  conditions,  36 

symptomatology,  39 

treatment,  40 
diet  in,  40 
Gram's  stain,  67 

iodin  solution,  technique  for  making,  68 


Hemooytometer.  Tiirck  ruled,  135 


INDEX  151 


Infective  variety  of  pyorrhea,  28-36 

age,  28 

bacteriology,  31 

differential  diagnosis,  32 

etiology,  28 

exacerbations,  32 

gum,  color  of,  30,  31,  35 

irritants,  29,  30 

occupation,  28 

pathology,  30 

prognosis,  35 

sex,  28 

social  conditions,  28 

symptomatology,  33 

treatment,  35 
diet  in,  36 
Interstitial  nephritic  variety  of  pyorrhea,  23-27 

age,  23 

bacteriology,  26 

diagnosis,  26 

differential  diagnosis,  26 

etiology,  23 

gum,  color  of,  25 

occupation,  23 

pathology,  25 

prognosis,  28 

sex,  23 

social  conditions,  23 

symptomatology,  27 

treatment,  28 

L 
Leptothrix  bucallis,  93 

culture  media,  93 

morphology,  93 

staining,  93 
Loeflaer's  methylene  blue,  technique  for  making,  69 


152  INDEX 


M 


Meat  infusion,  preparation  of,  70 

Mechanical  irritants,  variety  of  pyorrhea  resulting  from, 
55,  56 

age,  55 

bacteriology,  55 

diagnosis,  55 

differential  diagnosis,  55 

etiology,  55 

gum,  color  of,  55 

pathology,  55 

prognosis,  56 

sex,  55 

social  conditions,  55 

symptomatology,  56 

treatment,  56 
diet  in,  56 
Methylene  hlue,  technique  for  making,  69 

Loeffler's,  69 
Microtome,  medium  laboratory,  97 


Pathology,  94-123. 
Petri  dish,  81 

Pipette  for  mixing  blood  corpuscles  and  emulsion  of  bac- 
teria, 134 

application  of  drugs  with,  142 

making  of,  141 
Platinum  loop,  125 
Pre-senile  variety  of  pyorrhea,  41-45 

age,  41,  43 

alcohol,  effect  of,  41 

diagnosis,  43 

differential  diagnosis,  43 

etiology,  41 


INDEX 


153 


Pre-senile — Cont'd, 
gum,  color  of,  43 
pathology,  41 
prognosis,  45 
sex,  41 

social  conditions,  41 
symptomatology,  44 
treatment,  45 
diet  in,  45 

Reaction  of  vaccines,  137 


Senile  variety  of  pyorrhea,  46-49 

age,  46 

bacteriology,  47 

diagnosis,  47 

differential  diagnosis,  48 

etiology,  46 

gum,  color  of,  47 

occupation,  46 

pathology,  47 

prognosis,  48 

social  conditions,  46 

symptomatology,  48 

treatment,  49 
diet  in,  49 
Sodium  citrate  solution,  formula  for,  130 
Spirochseta  refringens,  93 

morphology,  93 

staining,  93 
Stain,  technique  for  making  Wright's,  64 

Bismarck-Brown  solution,  68 

carbol  gentian,  68 

Gram's,  67 

Gram's  iodin  solution,  68 


154  INDEX 

Stain — Cont'd. 
Loeffler's  methylene  blue,  69 
methylene  blue,  69 
Staining  slide,  technique  for,  62 
Standardization  of  vaccines,  132 
Staphylococcus  pyogenes  albus,  79-82 
growth  on  agar,  82 
in  bouillon,  82 
on  potato,  82 
isolation,  80 
morphology,  80 
Staphylococcus  pyogenes  aureus,  83-85 
growth  on  agar,  83 
in  bouillon,  84 
in  milk,  84 
on  potato,  83 
isolation,  83 
morphology,  83 
pathogenesis,  84 
staining,  83 
toxins,  84 
Staphylococcus  pyogenes  citreus,  85 
Staphylococcus  pyogenes  fetidis,  85-86 
growth  on  agar,  86 
in  bouillon,  86 
in  milk,  86 
on  potato,  86 
isolation,  86 
morphology,  86 
pathogenesis,  86 
staining,  86 
Sterilization  of  vaccines,  128 
Sterilizer,  hot  air,  81 
Streptococcus,  pyogenes,  87-89 
growth  on  agar,  87 

on  blood  serum  agar,  88 
in  bouillon,  88 


INDEX  155 


Streptococcus — Cont'd. 

on  gelatin,  88 

in  milk,  88 

on  potato,  87 
isolation,  87 
morphology,  87 
pathogenesis,  88 
staining,  87 
toxic  products,  88 


Technique  for  making  blood  smear,  61 

Bismarck-Brown  solution,  68 

capillary  pipettes,  141 

carbol  gentian,  68 

culture  media,  70 

Gram's  iodin  solution,  68 

Loeffler's  methylene  blue,  69 

methylene  blue,  69 

stains,  67 

vaccines,  124 

Wright's  stain,  64 
for  application  of  drugs  with  pipettes,  142 
for  collecting  blood  corpuscles,  130 
for  staining  slide,  62 
for  staining  smear  of  bacteria,  67 
for  sterilization  of  vaccines,  128 
for  tubing  and  sterilization  of  culture  media,  77 
for  vaccination,  137 
Thermal  irritants,  variety  of  pyorrhea  resulting  from,  57-58 
age,  57 

bacteriology,  57 
diagnosis,  57 
differential  diagnosis,  57 
etiology,  57 
gum,  color  of,  57,  58 


156  INDEX 

Thermal — Cont'd, 
occupation,  57 
pathology,  57 
prognosis,  58 
sex,  57 

social  conditions,  57 
symptomatology,  57 
treatment,  58 
Titration  of  agar,  74 

Trauma,  variety  of  pyorrhea  resulting  from,  49-52 
age,  49 

bacteriology,  50 
diagnosis,  51 
differential  diagnosis,  51 
.  etiology,  49 
gum,  color  of,  50 
occupation,  49 
pathology,  50 
prognosis,  51 
sex,  49 

social  conditions,  49 
symptomatology,  51 
treatment,  51 
Treatment  of  pyorrhea,  local  and  prophylactic,  143-146 

instrumentation,  143 
of  diabetic  variety,  23 
of  gastro-intestinal  toxemic  variety,  40 
of  infective  variety,  35 
of  interstitial  nephritic  variety,  28 
of  pre-senile  variety,  45 
of  senile  variety,  49 
of  variety  resulting  from  bacteriological  irritants,  60 

chemical  irritants,  54 

mechanical  irritants,  56 

thermal  irritants,  58 

trauma,  51 
Tiirck  ruled  hemocytometer,  135 


INDEX  157 

V 


Vaccines,  containers  for,  127 
reaction  of,  137 
standardization  of,  132 
sterilization  of,  128 
technique  for  making,  124 
Vaccination,  point  selected  for,  137 
position  of  arm  for,  138 
reaction  of,  137 
technique  for,  137 
Varieties  of  pyorrhea,  17-60 
diabetic,  18 

gastro-intestinar  toxemic,  36 
infective,  28 

interstitial  nephritic,  23 
pre-senile,  41 
senile,  46 
resulting  from  bacteriological  irritants,  58 

chemical  irritants,  52 

mechanical  irritants,  55 

thermal  irritants,  57 

trauma,  49 

W 

Wright's  stain,  technique  for  making,  64 

Z 
Zenker's  solution,  formula  for,  94 


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